2017 Open Enrollment Tobacco/E-Cigarette Premium Surcharge Affidavit Form

Willamette Dental Group maintains a proactive and preventative philosophy in our benefits program. The company is committed to promoting the health and well-being of its employees and their families, which includes being tobacco/e-cigarette-free.

Tobacco and e-cigarette users will be required to pay a premium surcharge of $50 per month for medical coverage beginning May 1, 2017.

What does it mean to be a “tobacco user”?
You are a “tobacco user” if you currently use tobacco products or have used tobacco products in the last 60 days, including cigarettes, electronic cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, dip, or any similar tobacco or nicotine related product. For the purposes of the surcharge, this does NOT include nicotine patches, nicotine gum or other items which are considered primarily tobacco cessation aids.

How can I avoid the surcharge?
By completing a tobacco cessation program through Quit for Life. Willamette Dental provides this program to you at no cost. Upon completion of the Quit for Life program your surcharge will be waived and reimbursed back to the beginning of the plan year. To enroll in the Quit for Life program, call 1 (866) QUIT-4-LIFE (1-866-7848454) or go to www.quitnow.net for more information. Once you have completed the Quit for Life program, please contact Benefits at x810165, to provide proof of completion of the Quit for Life program.

By completing this affidavit, I certify that my information is true and correct. I understand that falsification of company records may be grounds for termination of employment with WDG.