Peia Tobacco Affidavit PDF Details

Tobacco-free affidavits are commonly used in a variety of contexts, such as for employment, insurance, or legal purposes. For example, an employer may require a tobacco-free affidavit as part of a job application to demonstrate that the applicant does not use tobacco products. Similarly, an insurance company may request a tobacco-free affidavit as part of an application for life or health insurance, as tobacco use can increase the risk of certain health conditions.

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 Name Tobacco-Free Affidavit
Form Length 1 pages
Fillable? Yes
Fillable fields 17
Avg. time to fill out 3 min 43 sec
Other names smoking affidavit, tobacco use affidavit, affidavit of non-tobacco use

Form Preview Example





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


How to Edit Tobacco Affidavit Online for Free

The PDF editor was designed to be so simple as it can be. As soon as you follow the following steps, the procedure for preparing the PEIA document will be effortless.

Step 1: Click the "Get Form Now" button to get started on.

Step 2: You'll find all of the options that you may use on the document after you've accessed the PEIA editing page.

These particular areas will create the PDF file that you will be filling out:

portion of blanks in peia tobacco affidavit

Put the demanded data in the Policyholder, Signature, Date Agency, Name Authorized, Signature Account, Number Coverage, Code and Date area.

peia tobacco affidavit PolicyholderSignatureDate, AgencyName, AuthorizedSignature, AccountNumber, CoverageCode, and Date blanks to complete

Step 3: Hit the "Done" button. Now it's easy to upload the PDF file to your device. Besides, you can easily send it through electronic mail.

Step 4: Prepare at least several copies of the form to keep away from all of the future troubles.

Watch Tobacco Affidavit Video Instruction

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