Wellness
Wellness Initiatives
We at Marc Glassman Inc. care about the wellness of our employees and their families, and are proud to continue to offer valuable health insurance benefits to you. Outlined below are the Tobacco and Nicotine Affidavit and Preventive Care form for you and your enrolled spouse (if applicable). The completed form will need to be submitted or your per pay contributions will be subject to increase.
Submit form to:
Email: [email protected]
Mail: Attn: Benefits Dept., 5841 West 130th Street, Parma, OH 44130
RESOURCES
Tobacco & Nicotine Affidavit
- Employees and spouses on the plan must complete this form to avoid the surcharge(s). If you do not complete this form by 9/15/2022, your bi-weekly per pay contribution will increase by $80 for you and $80 for your spouse, if applicable, for a possible $160 per pay increase on 10/1/2022.
- By signing this form you are indicating you are tobacco and nicotine free for at least 3 months prior to 9/15/22.
- Tobacco products include cigarettes, cigars, electronic cigarettes, chewing or pipe tobacco or any other tobacco or nicotine product regardless of the frequency or method of use.
- If you currently use any of these nicotine/tobacco products, you can quit for 3 months or complete a No Cost Tobacco Cessation Program. If you quit or complete this program, your per pay contribution will NOT increase.
- Contact the Medical Mutual QuitLine at 1-866-845-7702 to enroll in the free Tobacco Cessation Program. You must sign-up for the program and complete 5 coaching calls before requesting a certificate of completion. Submit this certificate showing your program participation to Marc’s Benefits Department by 9/15/22.
- The Tobacco & Nicotine Affidavit is a binding acknowledgement; if provided information is later found to be false, it will be considered fraudulent and could lead to penalties including immediate rate increase and disciplinary action up to and including termination.
- MGI reserves the right to perform random tobacco and nicotine testing throughout the year.
Preventive Care Form
- Employees and Spouses on the plan must complete this form to avoid the surcharge(s). If you do not complete this form by 9/15/2022, your bi-weekly per pay amount will increase by $40 for you and $40 for your Spouse, if applicable, for a possible $80 per pay increase on 10/1/2022.
- This form will need to be signed by your physician indicating that you are up to date with your age, gender and health risk related preventive exams.
- Some examples of these exams are: yearly physical, blood work, colonoscopy, mammogram, prostate exam, pap smear. These preventive tests are at no cost to you.
- Exams that have been completed between 9/16/21 and 9/15/22 will be accepted.
| Program Options | Employee | Spouse |
| Stage 1: Tobacco Status – Employee Requirement | ||
| Complete Non-Tobacco Affidavit or Tobacco Cessation Program |
No additional surcharge applied | No additional surcharge applied |
| Failure to complete affidavit and/or Tobacco Cessation Program by 9/15/2022 |
$80 per pay contribution surcharge | $80 per pay contribution surcharge |
| Stage 2: Preventive Care – Employee and Spouse Requirement | ||
| Receive your annual physical and recommended preventive exams and labs based on your age, gender & health status |
No additional surcharge applied | No additional surcharge applied |
| Failure to submit the completed preventive care form by 9/15/2022 |
$40 per pay contribution surcharge | $40 per pay contribution surcharge |
