Get the free NON-TOBACCO USER AFFIDAVIT - stjude

SH GMP TOBACCO USER AFFIDAVIT Employee last name (please print legibly) First name Middle initial Department Typical work hours or shift (1st, 2nd, 3rd) Employee number In recognition of the health

How to fill out non-tobacco user affidavit

How to fill out non-tobacco user affidavit:

1. Obtain the non-tobacco user affidavit form from the appropriate source, such as your employer or insurance provider.
2. Carefully read through the form and familiarize yourself with the required information and declarations.
3. Begin by filling out your personal details, such as your full name, date of birth, address, and contact information, in the designated spaces provided.
4. Next, indicate whether you are the primary insured, a dependent, or both, by selecting the appropriate option.
5. Declare your non-tobacco user status by checking the box that corresponds to your usage. Usually, you will have options like "I am a non-tobacco user" or "I have not used tobacco in the last 12 months."
6. If applicable, provide additional information about any tobacco cessation programs or aids you have used in the past.
7. Sign and date the affidavit to authenticate your declaration.
8. Submit the completed form to the designated recipient or as instructed by your employer or insurance provider.

Who needs non-tobacco user affidavit?

1. Individuals who are applying for or renewing health or life insurance policies may be required to provide a non-tobacco user affidavit.
2. Employers may request employees to complete a non-tobacco user affidavit as part of their wellness program or to determine eligibility for certain benefits.
3. Some educational institutions or scholarship programs may require students to submit a non-tobacco user affidavit as a part of their application process.

Note: The specific requirements for who needs a non-tobacco user affidavit can vary depending on the insurance provider, employer, or organization requesting the form. It is important to follow the instructions provided by the requesting party to ensure compliance.

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What is non-tobacco user affidavit?

Non-tobacco user affidavit is a legal document where an individual declares that they do not use tobacco products.

Who is required to file non-tobacco user affidavit?

Individuals who do not use tobacco products are required to file non-tobacco user affidavit.

How to fill out non-tobacco user affidavit?

Non-tobacco user affidavit can be filled out by providing personal information and signing the document in front of a witness.

What is the purpose of non-tobacco user affidavit?

The purpose of non-tobacco user affidavit is to certify that the individual does not use tobacco products.

What information must be reported on non-tobacco user affidavit?

The non-tobacco user affidavit must include personal details, signature, and witness signature.