Form RL-311-F (03-10) RL-311-F (03-10) Evidence of Coverage Under an Employee Group Health Plan

Form Approved
OMB No. 3220-0082

RAILROAD RETIREMENT BOARD
844 NORTH RUSH STREET

CHICAGO, IL 60611-2092

WWW.RRB.GOV

OFFICE HOURS: 9:00 AM TO 3:30 PM
MONDAY THROUGH FRIDAY

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

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

To help us determine if is entitled to a Special Enrollment Period for Medicare
Part B (Medical Insurance) andlor premium surcharge relief for Part B premiums, please answer
the five 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
EVIDENCE OF COVERAGE UNDER AN EMPLOYER GROUP HEALTH PLAN
1. Has been covered under an employer Group Health Plan?
DYes - Complete Items 2-5
D No - Go to Item 5
2. Enter the name of the employer Group Health Plan.

I

3. Is still covered under the employer Group Health Plan?
_ _1_ _1
DYes - Enter the date coverage began.
D No - Enter the dates of coverage: From _ _1_ _1
To _ 1_ _1
4. Is the employee still working?
D Yes-Go to Item 5
D No - Enter the date employment ended.

1

-

1

5. Em ployer 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 and Title
phone Number (

)

I

Date

RL-311-F (03-10)

UNITED STATES RAILROAD RETIREMENT BOARD - 2

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. 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 comments regarding 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 60611-2092.

RL-311-F (03-10)