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Department of Human Resources
Agency of Administration
Vermont Department of Labor
DECLARATION OF HEALTH CARE COVERAGE
This form must be completed annually by employees who are not enrolled in a Health Care plan offered
by their employer, which provides both hospital and physician services.
Date______________
(Employer must retain this record for THREE years)
The purpose of this form is to obtain information regarding your health care coverage. The information certified
on this form will be used solely for the purposes of determining if your employer must pay Health Care
Contributions, as required by Act 191 of the 2006 Legislature, An Act Relating to Health Care Affordability for
Vermonters.
Print Employees Full Name: ____________________________
Employee ID or Social Security Number: _________________
Employee: Please complete Section A or B, sign and date, and return form to your employer.
Section A:
Complete this section ONLY IF you are eligible to enroll in the Health Care plan your employer
offers, but have declined or refused such coverage. Please check the appropriate box.
I do NOT have health care coverage that includes hospital and physician services.
I have declined or refused the employer’s plan because I have health care coverage that includes
hospital and physician services.
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Section B:
Complete this section if you are NOT eligible to enroll in the Health Care plan your employer
offers. Please check the appropriate box.
I do NOT have health care coverage OR I have coverage through VHAP or Medicaid.
I am a part-time employee who generally works less than 30 hours per week AND I have health care
coverage (other than VHAP or Medicaid) that includes hospital and physician services.
I am a seasonal employee who expects to work for this employer 20 or fewer weeks during this
calendar year AND I have health care coverage (other than VHAP or Medicaid) that includes hospital
and physician services.
NOTE to Employee: If at some point within the next year your health care coverage changes; you are
encouraged to complete another declaration.
By signature below, I certify the information contained in this form is the truth.
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Employee Signature
Date
VDOL Approved SOV HC-2 (7/07)