Non‐Smoker Premium Discount Affidavit


All employees who are enrolled in one of the company’s medical plans must complete and submit this affidavit within 60 days of completing enrollment.


In order to continue receiving medical plan coverage at a discounted rate, all employees who are enrolled in one of the company’s medical plans must certify that either: 

(1) They do not smoke and have not used any tobacco products within the last 12 consecutive months, or

(2) They have completed an approved smoking cessation program.

Cigna offers a smoking cessation program at no cost to its members. By completing this program or another approved smoking cessation program, employees will qualify for the discount even if they have used tobacco in the past 12 months.

Employees who use tobacco and have not completed a cessation program, or who fail to submit this certification within 60 days of completing enrollment, will be required to to pay an average of $125.00 per month (approximately $57.69 per pay) over the course of the 2021-22 plan year.

Important: Cigna’s smoking cessation program may take two-to-four weeks to complete. The program must be taken during non-working hours and must be completed within 60 days following enrollment before submitting this affidavit to continue receiving the non-smoker’s discount. 

Click here to learn how to register for Cigna’s approved smoking cessation program.

Please contact Human Resources with any questions or concerns you have regarding this affidavit.

Please submit one of the following selections.