2021 Tobacco/Smoke Free Affidavit
If you use tobacco and will be covered under the medical plan offered by CCG in 2021, you must complete
a Tobacco Cessation Program to avoid the surcharge.
In an effort to promote and support the health and wellness of employees, the Columbus Consolidated Government will impose a
$75.00 per month or $34.62 biweekly surcharge above the premium rate for all active employees/Pre-65 Retirees Premium Plans
including the Silver and Gold Plan. This surcharge is subject to change annually. The surcharge applies to employees/Pre-65 retirees,
who are tobacco users. For purposes of the premium surcharge, “tobacco use” is defined as:
Using any tobacco product (other than for religious or ceremonial use) including cigarettes, cigars, pipes, electronic
cigarettes, vaping; tobacco products applied to the gums (e.g., dipping, chewing tobacco, or snuff)
Uses tobacco products on average four or more times a week
Within no longer than the past six months.
Employee Name: Last 4 digits of SS#
Please read all 3 options and check one:
tify
I hereby acknowledge and certify that I HAVE NOT USED, tobacco products, in any form, within the past six (6) months.
The $75.00 per month/$34.62 biweekly surcharge WILL NOT apply. I also acknowledge and certify that it is my responsibility to
notify Human Resources within 10 days if I resume or begin using tobacco products, and as a result, I will be subject to the additional
$75.00 per month/$34.62 bi-weekly tobacco surcharge. Employees certifying that they are non-tobacco users are subject random
tobacco testing throughout the plan year.
I hereby acknowledge and certify that I have completed an approved tobacco-cessation program within the last 10 days;
therefore, making me eligible for the tobacco-free premium discount. (Attach documentation proof of program completion).
The $75.00 per month/$34.62 biweekly tobacco surcharge WILL NOT apply.
I hereby acknowledge and certify that I HAVE USED, tobacco products, in one of the forms identified herein, within the past six
(6) months. The $75.00 per month/$34.62 biweekly tobacco surcharge WILL apply.
Note:
The Columbus Consolidated Government supports its employees’ desire to quit; therefore, the CCG offers two tobacco
cessation programs: 1. Georgia and Alabama Department of Health’s Tobacco Quit Line Program Telephonic Format.
2. American Cancer Society FreshStart Program Face-to-Face Onsite Group Setting. The Health & Wellness Center will
also offer tobacco cessation medications.
If your status changes you are obligated to notify Human Resources within ten (10) days.
2021 Tobacco/Smoke Free Affidavit
If you use tobacco and will be covered under the medical plan offered by CCG in 2021, you
must complete a Tobacco Cessation Program to avoid the surcharge.
Plan Purpose: Substantial scientific evidence exists that the use of tobacco products is detrimental to the health of
the users of those products, contributes to higher health care costs, higher absenteeism, higher life insurance
premiums and decreased productivity. Accordingly, effective with the plan year beginning on January 1, 2021, the
Columbus Consolidated Government Employee/Pre-65 Retiree Health Plan is offering a Preferred Premium Plan
as an incentive to encourage employees and, pre-65 retirees to forgo the use of tobacco products.
Consequences of False Certification: The penalty for false certification of tobacco product abstinence is
imposition of the tobacco surcharge immediately following the discovery of false certification or positive random
nicotine test. The $75.00 per month/$34.62 biweekly tobacco surcharge WILL apply.
Removal of Tobacco Surcharge: The tobacco surcharge may be removed by completing the Tobacco Cessation
Program Option #1 or #2 offered by CCG. Once you have completed a tobacco cessation program and provided
certification (proof) of program completion, the tobacco surcharge will be removed and a retroactive refund of the
tobacco surcharge for that year will be issued.
Random Nicotine Testing: Employees must agree to random nicotine testing at the Columbus Consolidated
Government’s expense for evidence of tobacco product consumption. Failure to complete and submit a Tobacco/
Smoke Free Affidavit: EMPLOYEES WHO FAIL TO RETURN A COMPLETED, SIGNED AFFIDAVIT TO
HUMAN RESOURCES BY SEPTEMBER 30, 2020 WILL BE ENROLLED BY DEFAULT INTO THE
TOBACCO SURCHARGE RATE EFFECTIVE JANUARY 2021.
By affixing their signature, Employee certifies that the information set forth in this affidavit is true and correct.
_____________________________________
Printed Name of Employee
_______________________________________________ ________________________________
Signature of Employee Date
1360 220_____
Social Security # (last 4 digits only) Department Name Department Code
Mailing Address City/ State/ Zip Code
Please DO NOT inter-office or bring Tobacco Affidavit to HR. For processing, tobacco affidavit must be
completed and given to your Human Resources Coordinator.