Nonsmoker Discount Program
To: All employees on, or enrolling in, the health plan
Re: Nonsmoker Discount Program
Date: ______
In an effort to promote Health & Wellness for our employees, we are excited to announce the implementation of our Nonsmoker Discount Program for the upcoming plan year beginning __(insert start date for the plan year)__. A discount will be given on the health insurance premiums for any employee on the health plan who does not smoke or use tobacco products. [Note: you can make this for smoking only, or for all tobacco products]
The discount will amount to __ __ per pay period. [Note: you can have this as a percentage of their premium or as an actual dollar amount, and it can vary based on coverage options]
If you smoke or use tobacco products and would like to quit, we encourage you to enroll in a smoking cessation program. If you agree to participate in a company approved cessation program, you will receive the premium discount above, even if the program proves unsuccessful. However, you must provide proof that you completed the program or else you will lose the discount and be responsible for repaying any discount you received through that date. Proof of completion of the program must be submitted to ______by ______.
In order to receive the discount, you will be required to complete the enclosed affidavit and return it to ______by ______. Employees who do not timely return the affidavit will not receive the discount.
If you are interested in learning more about the programs available to help you stop using tobacco products, please stop by and see ______.
Thank you
Nonsmoker Discount Affidavit
Please review this affidavit carefully, answer the question(s) below, and then sign and date at the bottom. You must complete this affidavit and return it to ___(insert who and where to return it)___by __(insert date)____ in order to qualify for the discount.
If you do not smoke or use tobacco products you will receive the discount on your health insurance. Those employees who do smoke or use tobacco products will also receive the discount if they participate in and complete a company approved smoking cessation program, even if the program proves unsuccessful. The information you provide on this form will be kept confidential and will not be used for any purpose other than to determine your eligibility for the discount.
1. ¨ I am a smoker or tobacco user. (Please go to question #2).
¨ I am not a smoker or tobacco user. (Please skip question #2). You will receive the discount.
2. I am a smoker or tobacco user and:
¨ I will participate in and complete a company approved smoking cessation program. Information on company approved programs is available through Human Resources, and you are responsible for enrolling and completing the program and providing written verification of the program’s completion to Human Resources by ______.
¨ I will not participate in a company approved smoking cessation program and realize I will not receive the discount.
By signing this I certify that the above information is true and correct. I also certify that if the information I provided on this form changes, I will immediately notify Human Resources of such change. I understand that providing false information may subject me to repay the discount I received, and may also subject me to discipline, up to and including termination of employment.
Employee Signature ______Date ______