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

RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB No. 3220-0082

PROPOSED

WWW.RRB.GOV

OFFICE HOURS: M-F 9:00 AM TO 3:00 PM
CLOSED FEDERAL HOLIDAYS

TOLL-FREE NUMBER: 1-877-772-5772

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

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

Sincerely,

Enclosure: Envelope

RL-311F (XX-XX)

UNITED STATES RAILROAD RETIREMENT BOARD - 2
EVIDENCE OF COVERAGE UNDER AN EMPLOYER GROUP HEALTH PLAN
1. Is (or was) covered under an employer Group Health Plan?
Yes
No
2. If yes, provide the date the applicant’s coverage began.
*Note: If your company has changed healthcare providers during the beneficiary’s employment,
please include earliest date of coverage.

/

Month
Year
3. Has the coverage ended?
Yes
No
4. If yes, provide the date the applicant’s coverage ended.

/

Month

Year

/

Month
Year
5. When did the employee work for your company? (See below for additional information)
From
Month

/

To
Year

Month

/

Still Employed
Year

Month

/

Year

6. 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

Print Your Name and Title
Telephone Number

(

)

Date

Further explanation for question 5.
In general, an individual has “current employment status” if they are actively working as an
employee, are the employer (including a self- employed individual), or are associated with the
employer in a business relationship.
An individual also has “current employment status” if they are not actively working, but
meets all of the following conditions:
•

retains employment rights in the industry;

RL-311F (XX-XX)

UNITED STATES RAILROAD RETIREMENT BOARD - 3

•

•

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. 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.

RL-311F (XX-XX)