If interested, here is the wording (I sanitized it be removing my company's name)
Tobacco Surcharge
Consistent with <myCompanies> promotion of wellness, employees who are enrolled in a <myCompanies> medical plan who use tobacco products will pay a surcharge. If you enroll in a medical plan, you must indicate whether this surcharge applies to you by attesting below.
By completing this attestation, I certify that I understand and confirm the following to be true:
I currently do not use a tobacco product, nor have I used a tobacco product for the last six months
I understand the term "tobacco product" includes, but is not limited to: tobacco, tobacco-like, and products, such as cigarettes, cigars, pipes, electronic cigarettes, hookah pipes, snuff, and chewing tobacco (exceptions to this definition include approved smoking-cessation products, such as patches, gum, and prescriptions for smoking-cessation products prescribed by a doctor while under a doctor's care as part of a tobacco cessation program)
I understand that my eligibility for waiver of the tobacco user surcharge for medical benefits is based on this attestation
I understand that misrepresentation on this attestation constitutes fraud and may result in:
Loss of medical benefit eligibility for myself and my dependents
Retroactive liability for the tobacco surcharge
Disciplinary action up to and including termination of employment
I understand that if I begin tobacco use during the plan year, I must immediately notify the <myCompanies> Benefits Center to change my status