Sample Declaration Of Health Care Coverage Employee Form printable pdf download

Sample Declaration Of Health Care Coverage Employee Form

Sample Declaration of Health Care Coverage

Employee Form

This form is only to be used for employees of an employer who has offered to

pay some portion of a health care plan, for which the employee has opted not

to accept.

Enrollment Year _________

(Retain this record for 4 years)

The purpose of this form is to gather information regarding health care coverage. This

information will be used solely for the purposes of determining if Employer Health Care

Contributions are due by your employer, as required by Act 191 of 2006, An Act Relating to

Health Care Affordability for Vermonters.

Print Full Name: ________________________________________________

Employee ID or Social Security Number: ______________________________

I do have health care coverage.

NOTE: For purposes of this form, health care coverage includes: Catamount Health Plan,

Medicare, Medicaid, the Vermont Health Access Plan (VHAP), or Dr. Dynasaur or a private

or employer-sponsored insurance plan that includes both hospital and physician services.

I do not have health care coverage.

NOTE: If at some point health care coverage is obtained, you are encouraged to let your

employer know.

By signature below, I certify the information contained in this form is the truth.

___________________________________________

______________

Employee’s Signature

Date

HC-2 (3/07)

Sample Declaration Of Health Care Coverage Employee Form