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CABARRUSCOUNTY <br />PART I <br />OPEN ENROLLMENT <br />Affidavit Form 2007 <br />Cabarrus County Manager's Office <br />For your effort in achieving a healthy tobacco free lifestyle, we are offering you a health <br />insurance premium reduction for July 1, 2007. This form is due at open enrollment and <br />no later than May 11, 2007. <br />Last Name: <br />(please print clearly) <br />Employee SS#: -- <br />PART II <br />First Name: MI: _ <br />(please print clearly) <br />-- Department: <br />I. To enroll in health benefits beginning July 1, 2007, you must complete the Health Risk Assessment <br />(HRA) and health screening. Individual results are confidential and not shared with their <br />employer. The employer will only have access to a general overview of group results for statistical <br />reporting. Compliance is tracked and reported prior to enrollment. <br />2. Non-tobacco Use Discount: You are eligible for this discount if you have been tobacco free for at <br />least six months or since attending acounty-sponsored QuitSmart class or other smoking cessation <br />class in February/March 2007. <br />Place your initials next to those items that apply to you. <br />1. I have completed my online Health Risk Assessment and health screening. <br />2. I have not used any tobacco products in the last 6 months and will receive the <br />non-tobacco use discount. <br />Or <br />_ I have used tobacco products in the last 6 months, but successfully <br />completed a smoking cessation class and stopped using tobacco products. I <br />will receive the non-tobacco use discount. <br />3. _ I have used tobacco products in the last 6 months and I understand I will <br />not receive the non-tobacco use discount. <br />4.. I understand if I decide to begin smoking or using tobacco products, I <br />will notify the Human Resources office and my premiums will change. <br />Signature of Employee <br />Date <br />_ My signature above certifies that the information on this form is true and correct. Any person who <br />Initial knowingly and with intent to injure, defraud or deceive any insurer, files a statement ojjalse, incomplete <br />or misleading information may 6e guilty oja felony of the third degree and/or subject to discipline up to and <br />including dismissal under Act V!I or the Cabarrus County Personnel Ordinance. <br />F~ ~ ~ <br />