Last Name First Middle Initial
CWID Home Phone Work Phone
Have completed a tobacco cessation program
*For purposes of the enrollment period, you are a tobacco user if you have used tobacco products within the last 90
Employee's Signature: _________________________________________________ Date:_________________________
I certify that the above information is true and correct. Falsification of University documents may result in corrective
action, up to and including termination of employment; and/or demand of appropriate unpaid past premiums.
By electing this option, you are affirming that you have completed a tobacco
cessation program. Please provide date of completion:
By electing this option, you are affirming that you are a tobacco user.
Home Address (Street Address/City/State/Zip)
By electing this option, you are affirming that you do not use tobacco
TOBACCO AFFIDAVIT FOR CSC EMPLOYEES
As part of CSC's Tobacco-free Workplace Initiative and to encourage the wellness of our employees, a
tobacco-free incentive will be made available to employees which will reduce the cost of health coverage
contributions of the employee.
A tobacco user is defined as a person who has smoked or used any tobacco products, such as cigarettes,
cigars, smokeless tobacco products, e-cigarettes and/or vapors in the last 90 days*.
If you have used tobacco products within the last 90 days* you may still check the "No" box below, but ONLY
if you meet the definition of tobacco user and have a medical condition which made it inadvisable to quit
using tobacco products 90 days* before the effective date of coverage.
PLEASE PLACE AN "X" IN THE BOX THAT DESCRIBES YOUR TOBACCO USAGE.
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