AA-8 (XX-XX) Propo Widow Widower Application for Medicare - Medical Insuran

FORM APPROVED
OMB NO.3220-0082

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

DO NOT WRITE IN THIS SPACE

OFFICIALLY FILED

WIDOW/WIDOWER
APPLICATION FOR
MEDICARE

MONTH

DAY

OFFICE NUMBER

YEAR

APPROVED

After completing through Item 1 through 11, tab to the receipt on
page 7 and ' complete the top half.

APPLICATION NUMBER

DATE CODED
MONTH

DAY

YEAR

CODED BY

Section 1

General Instructions

Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, use Section
8, for this purpose. If you do not know the answer to a question, print “Unknown” in the space provided for the answer.
Also be sure to read the Important Notices on page 8.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would
enter January 1, 2024, as:
MO

DAY

YEAR

0 1 0 1 2 0 2 4
Some items in this application will not apply to you so you will not need to answer them. Based on your answer
to a question, you may be told to skip to another item number, or even another section. Follow the instructions
that tell you to “Go to” another item. These are designed to save you time and help you move though the
application quickly, filling in only necessary information. Do not skip any items unless directed to do so.
If you are completing this form on behalf of someone else, you must answer each question as it applies to the
applicant.

Section 2

Identifying Information

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 11 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
1

RAILROAD EMPLOYEE’S SOCIAL SECURITY NUMBER

2

RAILROAD RETIREMENT BOARD CLAIM NUMBER OR
SOCIAL SECURITY CLAIM NUMBER (IF ANY)

3

EMPLOYEE’S NAME

4

APPLICANT’S NAME
STREET NAME

PREFIX

5a

NUMBER

CITY AND STATE
ZIP CODE

FORM AA-8 (XX-XX) Destroy Prior Editions

5b

FOREIGN ADDRESS
(IF YES) COUNTRY

 YES
 NO

TELEPHONE NUMBER

6

DAYTIME TELEPHONE NUMBER
MONTH

7

YOUR DATE OF BIRTH

8

YOUR SEX

9

YOUR SURNAME AT BIRTH (IF DIFFERENT FROM ITEM 4)

10

YOUR SOCIAL SECURITY NUMBER
(If none, enter "TO BE SUBMITTED")

11

ENTER AN "X" IN THE BOX THAT SHOWS YOUR CURRENT
FILING STATUS

Section 3

DAY

YEAR

 MALE

Go to Item 10

 FEMALE

Go to Item 9

 WIDOW(ER)
 DIVORCED WIDOW(ER)
 REMARRIED WIDOW(ER)

Information about the Employee's Railroad Work and Military Service
 YES
 NO
 UNKNOWN

Go to Item 18
Go to Item 13
Go to Item 13

12

Has anyone ever filed an application for benefits or Medicare
under the Railroad Retirement Act on this account?

13

Enter the date the employee last worked in the railroad industry.

14

Did the employee have 120 or more months of
railroad service?

 YES

Go to Item 17

 NO

Go to Item 15

15

Did the employee have 60 or more months of railroad service
after 1995?

 YES

Go to Item 17

 NO

Go to Item 16

16

Has the employee ever been in active military service
in the U.S. Army, Navy, Air Force U.S Space Force or
Marines?

 YES

Go to Note and Item 17

 NO

Go to Item 17

MONTH

Note: If answered “YES,” you will have to submit proof of the employee’s military service. Please read
Chapter 6 of Booklet RB-3, Furnishing Evidence to Support Your Claim, to find out where to get proof of
military service. If you cannot submit proof, show, in Section 8, the branch of the service and the beginning
and ending date for each period of service. Creditable military service may be used to determine your eligibility
for Medicare.

FORM AA-8 (XX-XX) Page 2

YEAR

Regardless of whether the employee was retired at death, show the name and address of each railroad or nonrailroad
employer for whom the employee performed any part-time or full-time work during the last 3 years he/she worked. Print the
name and address of the most recent employer in “A,” the second in “B,” and so on. Enter the date each job began and
ended.

17

NAME AND ADDRESS OF EMPLOYER

BEGAN

NAME

A

ENDED

MONTH

YEAR

MONTH

YEAR

MONTH

YEAR

MONTH

YEAR

MONTH

YEAR

MONTH

NUMBER
AND
STREET
CITY, STATE
AND
ZIP CODE
NAME

B

NUMBER
AND
STREET
CITY, STATE
AND
ZIP CODE
NAME

C

YEAR

NUMBER
AND
STREET
CITY, STATE
AND
ZIP CODE

Section 4
18
19

Employee's Marital History

Was the railroad employee ever married before or after
your marriage to him/her?

 YES

Go to Item 19

 NO

Go to Item 20

Enter the following information about each of the railroad employee’s marriages, beginning with the one in effect
when the employee died, if any.
MARRIAGE BEGAN
DATE

CITY AND STATE

NAME OF SPOUSE

MARRIAGE ENDED
HOW (CHECK ONE)



EMPLOYEE’S
DEATH



SPOUSE’S
DEATH



DIVORCE



ANNULMENT



SPOUSE’S
DEATH



DIVORCE



ANNULMENT



SPOUSE’S
DEATH



DIVORCE



ANNULMENT

DATE

CITY AND STATE

FORM AA-8 (XX-XX) Page 3

Section 5
20

21

Applicant's Marital History

Were you ever married before or subsequent to your marriage
to the employee?

 YES

Go to Item 21

 NO

Go to Item 22

Enter the following information about each of your marriages beginning with your most recent one (do not include
marriage to the railroad employee).
MARRIAGE BEGAN
DATE

CITY AND STATE

NAME OF SPOUSE

MARRIAGE ENDED
HOW (CHECK ONE)

DATE

CITY AND STATE

 DEATH
 DIVORCE
 ANNULMENT
 DEATH
 DIVORCE
 ANNULMENT
 DEATH
 DIVORCE
 ANNULMENT

Section 6

Information About Social Security Entitlement

22

Have you ever filed an application for
social security benefits?

 YES
 NO

Go to Item 23

23

Did you file for social security benefits based
on your own record?

 YES
 NO

Go to Section 7

24

Enter the name of the person
on whose record you filed.

25

Enter the social security number of the
person on whose record you filed.

Section 7

Go to Section 7
Go to Item 24

Request for Enrollment in Medicare Medical Insurance Part B

In addition to applying for Hospital Insurance under Medicare Part A, you may elect to enroll in Medicare Part B. This plan helps pay
for physicians’ services and certain other medical expenses not covered by the hospital plan (Part A). If you enroll in this medical plan,
you will be required to make premium payments.
Initial Enrollment Period (IEP) is the 7-month period when you are first eligible for Medicare. This period begins 3 months before you
turn 65, includes the month you turn 65, and ends 3 months after you turn 65. Coverage begins the month after you signs up during
your IEP.
You are eligible for a Special Enrollment Period (SEP) if you are age 65 or older, or are under age 65, and disabled, did not elect to be
enrolled in Medicare Part B coverage when you became eligible and are covered under an employer group health plan based on your
own or your spouse's current employment.
The General Enrollment Period (GEP) is the time period every year from January 1 to March 31 when you can enroll in Medicare Part
B for the first time if you missed your Initial Enrollment Period (IEP) and do not qualify for the Part B Special Enrollment Period (SEP).
26

Do you wish to enroll in Medicare Part B?

27

Type of Medicare Part B enrollment?

FORM AA-8 (XX-XX) Page 4

 YES
 NO
 IEP
 SEP

27a

Complete this item only if you are filing in a Special Enrollment Period.

 GEP

I want my Part B coverage to begin on the first day of:
Month: ______________

Section 8
28

Year: _______________

Remarks

This section is to be used for the continuation of answers to other items. Be sure to include the item number at the beginning
of the answer you wish to continue. You may also use this space to enter any additional information that you feel may be
important to include.

FORM AA-8 (XX-XX) Page 5

Section 9
29

Will you have a guardian or other representative
sign the application on your behalf?

Note:

30

Certification
 YES

Go to “Note” and Item 30

 NO

Go to Item 30

If answered “YES,” the guardian or other representative of the applicant must sign this application.
That person must also complete and return Form AA-5, “Application for Substitution of Payee.”

I know that if I make a false or fraudulent statement in order to qualify for Medicare from the Railroad Retirement Board, (RRB)
I am committing a crime which is punishable under Federal law.
I certify that the information I gave to the RRB on this application is true to the best of my knowledge.
I agree to notify the RRB immediately:
• If there is a change in my marital status, or
• If I change my address.

YOUR SIGNATURE
(First Name, Middle
Initial, Last Name)
MONTH

DAY

YEAR

DATE

31

If this application is signed by mark ("X") in Item 29, two witnesses who know the person signing must sign below.
giving their full addresses and daytime telephone numbers.

a

Signature of Witness

Address (Number and Street)

City, State, ZIP Code

Daytime Telephone Number

b

AREA CODE

TELEPHONE NUMBER

AREA CODE

TELEPHONE NUMBER

Signature of Witness

Address (Number and Street)
City, State, ZIP Code

Daytime Telephone Number

FORM AA-8 (XX-XX) Page 6

Section 10

How to Return Your Application

Before you return your application, check to make sure that:
EVERY QUESTION THAT APPLIES TO YOU HAS BEEN ANSWERED.
YOU HAVE ENTERED “UNKNOWN” IN ANY ANSWER SPACE FOR WHICH YOU WERE UNABLE
TO ANSWER A QUESTION.
YOU HAVE SIGNED AND DATED THE APPLICATION.
YOU HAVE INCLUDED ALL THE NEEDED PROOFS LISTED IN THE LETTER YOU RECEIVED
WITH THIS APPLICATION.

When you received your application you should also have received a pre-addressed envelope. If you do not
have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page 7
of this application. No matter which envelope you use, you must put the correct postage on the envelope. Be
careful to provide enough postage, because your application and the accompanying forms may weigh more
than a standard letter. The U.S. Postal Service will not deliver your application unless it has the correct postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:

NEEDED PROOFS
THE APPLICATION FORM ITSELF
ADDITIONAL FORMS YOU WEREASKED TO COMPLETE

Note: Make no entries on page 7, which is the receipt for your claim. After the RRB receives your
application, they will complete the blanks on the receipt and send it back to you. When you receive it,
you will know that the RRB has received your application and has started the work needed to determine
if you are entitled to Medicare. If you do not receive the receipt within two weeks after you filed this
application, please contact us so we can find out what is causing the delay.

FORM AA-8 (XX-XX) Page 7

Receipt For Your Claim

Employee's Name

Applicant's Name

Railroad Retirement Board Claim Number

Date Claim Received

Your application for Medicare has been received and will be processed as quickly as possible. If you change
your address, or if your marital status changes, you or your representative should report the change. Always
give us your claim number when writing or calling about your claim. If you have any questions about your
claim, we will be glad to help you. If you need to personally visit one of our field offices, please call for an
appointment. You will not be refused service if you do not have an appointment, but our staff can serve you
better when an appointment is made. Railroad Retirement Board offices are open to the public from 9:00 AM
to 3:30 PM, Monday, Tuesday, Thursday and Friday and from 9:00 AM to 12:00 PM on Wednesday.
Always Report These Changes to the RRB

► Change of Address – To avoid delay in receipt of RRB correspondence, you should also file a regular
change of address notice with your post office.

► Change of Marital Status – If you remarry or become divorced or your marriage ends due to the death
of your spouse.

How to Report Changes
You can make your reports either by telephone, mail, or in person, whichever you prefer. When a change
occurs after you are enrolled for Medicare, you or your representative should report the change at once.
To report any of the above changes, contact:

Telephone Number:
If for some reason you cannot contact that office, you should contact:

U S RAILROAD RETIREMENT BOARD 844
N RUSH ST
CHICAGO IL 60611-1275
(877) 772-5772
FORM AA-8 (XX-XX) Page 8

ATTESTATION
I understand that anyone who, knowingly and willfully — (1) falsifies, conceals, or covers up by any trick, scheme,
or device a material fact; or (2) makes any materially false, fictitious, or fraudulent statements or representations,
or makes or uses any materially false writing or document knowing the same to contain any materially false,
fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for health care benefits,
items, or services, shall be fined or imprisoned not more than 5 years, or both.
Signature (Do not print)
Date Signed
Month

Day

Year

FORM AA-8 (XX-XX) Page 9

Important Notices
Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. The Privacy Act requires that the
Railroad Retirement Board (RRB) tell you the following whenever we ask you for information.
1) The law which allows us to ask for the information;
2) whether that law requires you to give us that information and what, if anything, might happen to you if you do not give it to us;
3) the reason why the information is requested; and
4) the persons, organizations, and agencies to which we may release the information without your permission.
The RRB is authorized to collect the information on this form under sections 7(b) and 7(d) of the Railroad Retirement Act and sections
226, 1836 and 1840 of the Social Security Act, as amended. The information on this form is needed to enable the RRB to determine
your eligibility to monthly benefits and entitlement to hospital and/or medical insurance coverage. While you do not have to furnish the
information requested on this form, no hospital or medical insurance can be provided until an application has been received. Failure to
provide all or part of the information requested could prevent an accurate and timely decision on your claim and could result in the loss
of hospital or medical insurance.
Although the information you furnish on this form is almost never used for any other purpose than stated above, there is a possibility
that for the administration of the Railroad Retirement, Social Security, and the Centers for Medicare & Medicaid Services programs,
information may be disclosed to another person or to another government agency as follows:
1) Beneficiary identification, enrollment status and premium deductions information may be released to the Social Security
Administration and the Centers for Medicare & Medicaid Services to correlate action with the administration of Title ll and Title XVlIl
(MEDICARE) of the Social Security Act.
2) Beneficiary identification may be disclosed to third party contacts to determine if incapacity of the beneficiary or potential beneficiary
to understand or use benefits exists, and to determine the suitability of a proposed representative payee.
3) Jurisdictional clearance, premium rate, coverage election, paid-thru date, and amounts of payments in arrears may be released to
the Social Security Administration and the Centers for Medicare & Medicaid Services to assist in administering Title XVlll of the Social
Security Act.
4) The last address information may be disclosed to the Department of Health and Human Services in conjunction with the Parent
Locator Service.
5) Beneficiary identification, entitlement data and rate information may be referred to the Department of State and embassy officials to
aid in the development of applications, supporting evidence and the continued eligibility of beneficiaries and potential beneficiaries
living abroad.
6) Records may be released to the Government Accountability Office for auditing purposes and for collection of debts arising from
overpayments under Title XVlll of the Social Security Act, as amended.
7) Disclosure may be made to a congressional office from the record of an individual in response to an inquiry from the congressional
office made at the request of that individual.
8) Pursuant to a request from an employer covered by the Railroad Retirement Act or the Railroad Unemployment Insurance Act,
information regarding the RRB’s determination of Medicare entitlement, entitlement data and present address may be released to the
requesting employer for the purposes of determining entitlement to and rates of supplemental benefits payable under private employer
welfare benefit plans.
We estimate this form takes an average of 8 minutes per response to complete, including the time for reviewing the instructions,
obtaining the data, and reviewing the completed form. 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: Railroad Retirement Board, ATTN: Bureau of
Information Services/Policy & Compliance, 844 N. Rush St., Chicago, IL 60611-1275.
Computer Matching and Privacy Protection Act Notice
The Computer Matching and Privacy Protection Act of 1988 requires the Railroad Retirement Board (RRB) to advise you that
information you have provided may be used, without your consent, in automated matching programs. These matching programs are a
computer comparison of RRB records with records kept by other Federal, state, or local governmental agencies. Information from
these matching programs can be used to establish or verify a person’s eligibility for Federally funded or administered benefit programs
and for repayment of payments or delinquent debts under these programs.

FORM AA-8 (XX-XX) Page 10