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<br />'. <br />. <br /> <br /> <br />CABARRUSCOUNTY <br />OPEN ENROLLMENT <br /> <br />Affidavit Form 2006 <br /> <br />Cabarrus County Manager's Office <br /> <br />PART I <br /> <br />For your effort for achieving a healthy lifestyle, we are offering you a health insurance <br />premium reduction for July I, 2006. This form is due at open enrollment and no later <br />than May 12,2006, <br /> <br />(please print clearly) <br /> <br />First Name: <br />(please print clearly) <br /> <br />Ml: <br /> <br />Last Name: <br /> <br />Employee SS#: <br /> <br />Department: <br /> <br />PART II <br /> <br />1, To enroll in health benefits beginning July I, 2006, you must complete the Health Risk Assessment <br />(HRA) and health screening. Individual results are confidential and not shared with employer. The <br />employer will only have access to a general overview of group results for statistical reporting. <br />Compliance is tracked and reported prior to enrollment. <br /> <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 a county-sponsored QuitSmart class or other smoking cessation <br />class in January or February 2006. <br /> <br />Place yonr initials next to those items that apply to you. <br /> <br />1. _ I have completed my online Health Risk Assessment and health screening, <br /> <br />2, _ I have not used any tobacco products in the last 6 months and will receive the <br />non-tobacco use discount. <br /> <br />Or <br /> <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 /> <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 /> <br />4. _ I understand if! decide to begin smoking or using tobacco products, I <br />will notifY the Human Resources office, <br /> <br />Signature of Employee <br /> <br />Date <br /> <br />My signature certifies thalthe 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 of false, <br />incomplete or misleading information may be subject to discipline up to and including dismissal under Act <br />VII or the Cabarrus County Personnel Ordinance. <br /> <br />G-5 <br />