Get the free 2011 NON-TOBACCO USERS AFFIDAVIT FORM

STATE HEALTH BENEFIT PLAN SHBP 2011 NON-TOBACCO USERS AFFIDAVIT FORM ACTIVE EMPLOYEES Policyholder/Plan Member Name Social Security Number Health Plan Options circle one CIGNA HDHP CIGNA HMO CIGNA HRA UHC HDHP UHC HMO UHC HRA Check all of the following I hereby certify that all covered members have not used any tobacco products within the past 12 months this plan year wellness program with the above health plan I understand that as a State Health Benefit Plan member I have the responsibility...

How to fill out 2011 non-tobacco users affidavit

How to fill out 2011 non-tobacco users affidavit

1. Read the instructions carefully to understand the requirements for filling out the 2011 non-tobacco users affidavit.
2. Start by providing your personal information such as your name, address, and contact details.
3. Ensure you accurately state whether you are a tobacco user or non-tobacco user.
4. If you are a non-tobacco user, provide any supporting documentation or evidence if required.
5. Sign and date the affidavit after you have completed all the necessary information.
6. Submit the filled-out 2011 non-tobacco users affidavit according to the instructions provided.

Who needs 2011 non-tobacco users affidavit?

1. Anyone who is required to provide evidence of being a non-tobacco user in the year 2011 may need the 2011 non-tobacco users affidavit.
2. This affidavit is typically required in certain legal or insurance proceedings where tobacco usage has implications.
3. Specific individuals or organizations requesting the affidavit will provide the necessary details and instructions on who needs to submit it.

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