RL-311-F (xx-xx) Evidence of Coverage Under an Employee Group Health Plan

RAILROAD RETIREMENT BOARD

Form Approved
OMB No. 3220-0082

844 NORTH RUSH STREET, ROOM 901
CHICAGO, IL 60611-1275
E-MAIL: chicago@rrb.gov

OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM
WEDS. 9:00 AM TO 12:00 PM - CLOSED FEDERAL HOLIDAYS

PROPOSED
TOLL-FREE NUMBER: 1-877-772-5772
FACSIMILE NUMBER: 1-312-751-7136

RRB Claim Number:
Name of Claimant:
Claimant’s SS No.:

To help us determine if
is entitled to a Special Enrollment Period for Medicare Part B (Medical
Insurance) and/or premium surcharge relief for Part B premiums, please answer the five items
below and return this page to us using the enclosed envelope, or via facsimile to the number
shown above.
If you have any questions, please call the toll-free telephone number shown above.
Sincerely,

Enclosure: Envelope

EVIDENCE OF COVERAGE UNDER AN EMPLOYER GROUP HEALTH PLAN
1. Has
been covered under an employer Group Health Plan?
Yes - Complete Items 2-5
No - Go to Item 5
2. Enter the name of the employer Group Health Plan.
3. Is

still covered under the employer Group Health Plan?
Yes - Enter the date coverage began.
_____/_____/________
No - Enter the dates of coverage: From _____/_____/________ To ____/_____/________

4. Is the employee still employed?

Yes

No (See page 2 for additional information)

Employment Start Date: _____/_____/________

End Date: _____/_____/________

5. Employer Certification - Knowing that anyone who makes a false or fraudulent statement for the
purpose of obtaining benefits from the RRB is committing a crime punishable under federal law, I
certify that the information is true, correct, and complete.
Signature
Print Your Name and Title
Telephone Number

(

)

Date

RL-311F (xx-xx)

UNITED STATES RAILROAD RETIREMENT BOARD - 2

Further explanation for question 4.
In general, an individual has “current employment status” if he/she is actively working as an
employee, is the employer (including a self- employed individual), or is associated with the
employer in a business relationship.
An individual also has “current employment status” if he or she is not actively working, but
meets all of the following conditions:




retains employment rights in the industry;
employment has not been terminated by the employer (if the employer provides the
coverage); or membership in the employee organization has not been terminated (if the
employee organization provides the coverage);
is not receiving disability benefits from an employer for more than 6 months

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The Railroad Retirement Board (RRB) is authorized to collect the information requested on this
form under Sections 7(b)6 and 7(d) of the Railroad Retirement Act. The information obtained from
this form will be used for determining whether the claimant applying for Part B under Medicare may
be entitled to a Special Enrollment Period and/or premium surcharge relief because of coverage
under an employer Group Health Plan. Although you are not required to furnish this information, if
you fail to do so, the claimant may not be considered eligible by the RRB to receive these benefits.
We estimate this form takes an average of 10 minutes per response to complete, including the time
for reviewing the instructions, obtaining the data, and reviewing the completed form. Federal
agencies may not conduct or sponsor, and respondents are not required to respond to a collection
of information unless it displays a valid OMB number. If you wish, send comments regarding the
accuracy of our estimate, or any other aspect of this form, including suggestions for reducing
completion time, to the Associate Chief Information Officer for Policy and Compliance, Railroad
Retirement Board, 844 N. Rush St., Chicago, IL 60611-1275.

RL-311F (xx-xx)