RL-311-F (proposed Evidence of Coverage Under a Group Health Plan

Form Approved
OMB NO.3220-0082

RRB Claim Number
Name of Claimant
Claimant's SS No.
Name of Employee
Employee'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, then sign and date the Employer Certification and return this page to us using the
enclosed envelope.
If you have any questions, please call our office at the telephone number shown above.
Sincerely,

1. Has the claimant been covered under an employer Group Health Plan?
2. Name of employer Group Health Plan:
3. Date of coverage under the employer Group Health Plan:

Yes

No

Yes - Go to Employer Certification
No - Go to Item 5

4. Is the employee still working?

5. Date the employer's employment terminated:
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:
PRINT YOUR TITLE:
TELEPHONE NUMBER:

(

)

DATE

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 rr~inutesper 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 corr~mentsregarding the
accuracy of our estimate, or any other aspect of this form, including suggestions for reducing
completion time, to the Chief of Information Resources Management, Railroad Retirement Board,
844 N. Rush St., Chicago, IL 6061 1-2092.