Peia Tobacco Affidavit PDF Details

The Peia Tobacco Affidavit Form, released in May of 2014, is a list of questions compiled by the Paraguayan government to investigate whether or not certain individuals have been involved in the smuggling, sale and/or distribution of tobacco products in Paraguay. The form is lengthy and detailed, requiring specific information about each transaction, including dates, quantities and payment methods. The affidavit also asks for the name and contact information of any witnesses or other individuals with knowledge of the alleged activities. violators can face steep fines and imprisonment. completing this form accurately is critical for those who wish to clear their name of any suspicion.

Here is the information concerning the file you were looking for to complete. It will show you the time it will require to fill out peia tobacco affidavit, what parts you need to fill in and some other specific details.

Form NamePeia Tobacco Affidavit
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other nameswv peia tobacco affidavit, peia tobacco affidavit, policyholder, WV

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West Virginia Public Employees Insurance Agency


State ZIP

Tobacco Affidavit

You may complete this affidavit to notify PEIA if your tobacco status changes. Please mark which members of the family (if any) use tobacco and sign the affidavit. If none of the people enrolled on your health coverage uses tobacco you will receive any available discount on your health premiums. If the policyholder does not use tobacco, he or she will receive a discount on any Optional Life Insurance premiums.

Who uses tobacco:


Dependent (spouse and/or children)

No Tobacco Users

I certify that the above information is true and correct. I further certify that if this information changes I will notify the plan of the change in writing. I acknowledge by signing this form that WVPEIA or its agents have access to my medical records to check my tobacco use status. I understand that providing false information on this form is illegal and that those who provide false information may be prosecuted. I hereby consent, for myself and my covered dependents, to the release to PEIA of all medical and prescription drug information needed to process claims, determine coverage, review utilization, investigate complaints, assess quality of care, evaluate plan performance or any other process involved in my treatment, payment of claims or health care operations.

Policyholder Signature ________________________________________________ Date __________________

Active Employees: Return this form to your Benefit Coordinator for completion of the Agency portion below.

Retired Employees: Mail the affidavit directly to PEIA, Attention: Open Enrollment Unit, 601 57TH ST., SE, SUITE 2, CHArleston, WV 25304-2345.

Agency Name

Account Number

Coverage Code

Authorized Signature


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