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Certification Regarding Tobacco or E-cigarette Use

Certification Regarding Tobacco or E-cigarette Use SCPEBA 042020 Certification Regarding Tobacco or E-cigarette Use Check the appropriate box, sign and return to PEBA, 202 Arbor Lake Drive, Columbia, SC 29223. Subscriber name:_____ Subscriber BIN/SSN: _____ Non- Tobacco or E-cigarette user I certify that I am eligible for the non- Tobacco -use premium by checking this box and returning this form to PEBA. By checking this box, I certify truth and understanding of the following: I certify that all persons covered on my health insurance coverage through PEBA (including myself and any dependents) are not currently using, and have not used, any Tobacco products or electronic cigarettes in any form (cigarettes, cigars, pipe, oral Tobacco products, etc.) within the last six months. I certify that if this information changes at any time in the future, while I have health insurance coverage through PEBA, I will notify PEBA of such change within 31 days through completion and resubmission of this form.

Certification Regarding Tobacco or E-cigarette Use SCPEBA 042020 Certification Regarding Tobacco or E-cigarette Use Check the appropriate box, sign and return to S.C. PEBA, 202 Arbor Lake Drive, Columbia, SC 29223.

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