Get the free Non-Tobacco User Affidavit

This document is an affidavit for applicants to certify their non-use of tobacco products, impacting their insurance premium rates and coverage eligibility.

How to fill out non-tobacco user affidavit

How to fill out Non-Tobacco User Affidavit

1. Obtain a copy of the Non-Tobacco User Affidavit form from your employer or insurance provider.
2. Read the instructions carefully to understand the declaration requirements.
3. Fill in your personal information, including your full name, address, and contact details.
4. Indicate your status as a non-tobacco user by checking the appropriate box or section.
5. If required, provide the date when you last used tobacco products.
6. Sign and date the affidavit to certify that the information provided is accurate.
7. Submit the completed affidavit to the designated person or department as instructed.

Who needs Non-Tobacco User Affidavit?

1. Individuals seeking to receive health insurance benefits or lower premiums by declaring their non-tobacco use.
2. Employees who are required by their employer to confirm their non-tobacco status for wellness programs.
3. Applicants for certain health-related insurance policies that incentivize non-tobacco use.

People Also Ask about

What does it mean when it says I attest that I am a tobacco user?

Tobacco attestation is the section of the enrollment process for the State Health Plan that asks about your tobacco use. All State Health Plan members MUST complete the tobacco attestation to avoid the default surcharge of $60 a month for the next year's premiums.

What is defined as tobacco use?

Tobacco use may be defined as any habitual use of the tobacco plant leaf and its products. The predominant use of tobacco is by smoke inhalation of cigarettes, pipes, and cigars. Smokeless tobacco refers to a variety of tobacco products that are either sniffed, , or chewed.

Do vapes count as tobacco users?

Use of e-cigarettes and inhalation of their contents is known as vaping (American Cancer Society, 2022). The liquids used in e-cigarettes do not contain tobacco, but they do contain nicotine derived from tobacco, and thus the U.S. Food and Drug Administration (FDA) classifies them as a tobacco product.

What is non-tobacco?

adjective. non·​to·​bac·​co ˌnän-tə-ˈba-(ˌ)kō : not being or containing tobacco. nontobacco cigarettes. nontobacco nicotine products.

What qualifies as a tobacco user?

A tobacco user is a person who has used any tobacco products, as defined in the policy, five or more times within the past three consecutive months.

What counts as a tobacco user?

“Tobacco use” means a person has used a tobacco product an average or four or more times per week for the past six months. A state can increase the number of times per week or reduce the “look-back” period to less than six months. Check with your state Marketplace to learn more.

What constitutes regular tobacco use?

National Health Interview Survey (NHIS) Information about cigarette smoking is obtained for adults age 18 and older. Current cigarette smokers are defined as ever smoking 100 cigarettes in their lifetime and currently smoking every day or some days.

For pdfFiller’s FAQs

What is Non-Tobacco User Affidavit?

A Non-Tobacco User Affidavit is a legal document that individuals use to declare that they do not use tobacco products.

Who is required to file Non-Tobacco User Affidavit?

Typically, employees or individuals who wish to receive health insurance benefits with a non-tobacco user discount are required to file the Non-Tobacco User Affidavit.

How to fill out Non-Tobacco User Affidavit?

To fill out a Non-Tobacco User Affidavit, individuals need to provide their personal information, affirm their non-use of tobacco products, and usually sign and date the document.

What is the purpose of Non-Tobacco User Affidavit?

The purpose of the Non-Tobacco User Affidavit is to help employers or insurance providers determine eligibility for discounts or benefits based on non-use of tobacco.

What information must be reported on Non-Tobacco User Affidavit?

The information that must be reported typically includes the individual's name, contact information, a statement affirming non-use of tobacco, and possibly the date of the affidavit.