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I I CABARRUSCOUNTY OPEN ENROLLMENT I I Affidavit Form 2006 Cabarrus County Manager's Office I I PART I For your effort for achieving a healthy lifestyle, we are offering you a health insurance premium reduction for July 1, 2006. This form is due at open emollment and no later than May 12,2006. I (please print clearly) First Name: (please print clearly) MI: Last Name: I Employee SS#: Department: I PART II I 1. To enroll in health benefits beginning July 1, 2006, you must complete the Health Risk Assessment (HRA) and health screening. Individual results are confidential and not shared with employer. The employer will only have access to a general overview of group results for statistical reporting. Compliance is tracked and reported prior to enrollment. I 2. Non-tobacco Use Discount: You are eligible for this discount if you have been tobacco free for at least six months or since attending a county-sponsored QuitSmart class or other smoking cessation class in January or February 2006. I Place your initials next to those items that apply to you. 1. _ I have completed my online Health Risk Assessment and health screening. I 2. _ I have not used any tobacco products in the last 6 months and will receive the non-tobacco use discount. I Or _ I have used tobacco products in the last 6 months, but successfully completed a smoking cessation class and stopped using tobacco products. I will receive the non-tobacco use discount. I 3. _ I have used tobacco products in the last 6 months and I understand I will not receive the non-tobacco use discount. I 4. _ I understand if! decide to begin smoking or using tobacco products, I will notify the Human Resources office. I Signature of Employee Date I My signature certifies that the information on this form is true and correct. Any person who initial knowingly and with intent to injure, defraud or deceive any insurer, files a statement offalse, incomplete or misleading information may be subject to discipline up to and including dismissal under Act VII or the Cabarrus County Personnel Ordinance. ;/'t 5 \.J- I