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Places for People, Inc.
2016 Annual Enrollment
2016 Page 13
A Tobacco-Free Premium Discount is linked to our medical plan options as of January 1, 2016.
All employees electing coverage must certify whether or not they use tobacco products.
To be eligible for the Tobacco-Free Premium Discount you must not use tobacco in any form. A
tobacco user
is defined as an individual who currently uses any form of tobacco, regardless of the
method and frequency of use. Tobacco includes any form of tobacco products that are smoked
(cigarettes, cigars, pipes, electronic cigarettes), applied to the gums (dipping, chewing tobacco, or
snuff) and/or inhaled.
The Tobacco-Free Premium Discount varies by health plan chosen.
Please indicated your current status
:
__
I
do not
smoke or use tobacco products.
__
I
do
smoke or use tobacco products.
____________________________________________________ _______________
Signature
Date
If a tobacco user status option is not selected, the Tobacco-Free Premium Discount will not be
available in 2016, regardless of employee’s tobacco usage.
Note:
If it is unreasonably difficult for you to achieve the above standard for the Tobacco-Free
Discount due to a medical condition, or if it is medically inadvisable as determined by your physician
for you to attempt to achieve the above standard for the discount, documentation must be submitted
by your physician to the Human Resources contact.
FRAUD NOTICE:
Intentional falsification or making false statements is a fraudulent act and is subject to disciplinary
action, up to and including termination of employment.