Smoking/Tobacco Cessation Program Claim Reimbursement Form

Employee Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Type of Smoking Cessation Program

Date of Service or Date Prescription filled

Amount of Reimbursement Requested

The lifetime maximum benefit for the Smoking/Tobacco Cessation Program is $1,000 per person. This benefit covers expenses associated with the following: Bupropion SR, Nicotine gum, Nicotine nasal spray, Nicotine patch, physician visits or any program whose specific purpose is to aid in smoking cessation. Vaping systems or programs do not qualify. To receive reimbursement through Lakeside International Trucks Smoking/Tobacco Cessation Program please attach your receipts to this form and submit them to Human Resources.

DEPARTMENT

INVENTORY

SHOWROOM

OTHER RESOURCES

Smoking/Tobacco Cessation Program Claim Reimbursement Form

Smoking/Tobacco Cessation Program Claim Reimbursement Form