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Little
Rock
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Non-Tobacco or Non-Nicotine Use Attestation
Please review this attestation carefully and complete this form.
The information you provide below will be kept confidential.
City of Little Rock Employees who participate in the health plan and use Tobacco or
Nicotine products and agree to complete a Tobacco Cessation program will not be
charged the nicotine surcharge.
Information on the Quit for Life smoking cessation program is available on myuhc.com
and posted on the City’s Internet under the Benefits section. You may participate in
the smoking cessation program of your choice, however it is your responsibility to
provide proof you have completed the program no later than March 31, 2019.
Please initial by your current nicotine/tobacco status.
________
I attest that I do not use tobacco or other nicotine products including e-
(INTIAL)
cigarettes and vapors.
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I am a tobacco or nicotine user. I understand I will be charged $25.00 per
(INTIAL)
month if I continue to use tobacco or nicotine.
If you are a Nicotine or Tobacco User select from the following options.
I will complete a smoking cessation program and provide documentation
to Human Resources Benefits & Risk Division by March 31, 2019. I
understand failure to submit documentation will result in a charge of
$25.00 per month.
I will not participate in a smoking cessation program. I understand I will be
charged $25.00 per month.
(Print Name)
Emp. ID # Department
Signature
Date
Please submit all forms to hrbenefits@littlerock.gov
click to sign
signature
click to edit
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