If You Or A Family Member Was Affected By The ERISA Healthcare Insurance Tobacco Surcharge, We Want To Hear From You.

Both users and non-users of tobacco-related products could have been impacted by tobacco-related healthcare insurance surcharges tied to employer benefit plans. 

This form is intended to help identify potential eligibility related to ongoing ERISA investigations involving healthcare and payroll deductions.

Completing this form does not guarantee a claim and does not create an attorney-client relationship.