I hereby certify that I have coverage under the Chippewa Falls School District’s sponsored Health Insurance Plan and that I have achieved 3 out of the 5 conditions below:

* I Participated in the 2017 Biometrics Screening through the Cardinal Healthy Primary Care Clinic
I have not used any tobacco product in the previous twelve (12) months
I do not have a conviction for OWI, speeding ticket or a positive drug test in the past three (3) years
I am at a weight range with a Body Mass Index less than 30
I have completed the Health Risk Assessment on the Wellness Portal by November 30, 2017

* - Indicates that this item is required.

If I certify to the above, I understand I will receive a monthly credit on my share of the health insurance premium. $20 per month for the family plan and $10 per month for the single plan. This credit will be in effect beginning January 1, 2018 – December 31, 2018 or until any of the above conditions are violated.

I also understand that if I make a false certification, all premium credits that I had received, will be immediately voided and will be subject to repayment.

If it is unreasonably difficult for you to achieve the standards for the reward under this program due to a medical condition, or if it is medically inadvisable for you to attempt to achieve the standards for the reward under this program, e-mail HumanResources@chipfalls.org and we will work with you to develop another way to qualify for this reward.