Form Hc-2 - Declaration Of Health Care Coverage printable pdf download

THIS FORM MUST BE COMPLETED ANNUALLY

Vermont Department of Labor

DECLARATION OF HEALTH CARE COVERAGE

EMPLOYER: This form is ONLY to be completed by employees if you offer and pay a portion of a

health care plan that provides hospital and physician services AND… 1) the employee is eligible to

enroll in such plan but elects not to; OR… 2) the employee can potentially be excluded from such

reporting as they may meet the Health Care Contribution reporting definitions as a “part-time” or

“seasonal” employee. DO NOT RETURN THIS DOCUMENT TO THE VERMONT DEPARTMENT

OF LABOR.

Date ___________________________

Employer’s Legal Name:

___________________________________________________

Print Employee’s Full Name:

_________________________________________________

Employee ID or Social Security Number: _________________________________________

EMPLOYEE: Please complete Section A or B, sign and date, and return form to your employer.

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 under 21 V.S.A., Section 2003.

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.

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 hour per week AND I have health care

coverage from a source 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 from a source 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.

___________________________________

________________

Employee Signature

Date

HC-2 (8/08)

Employer - Retain this document in your records for THREE YEARS.

Form Hc-2 - Declaration Of Health Care Coverage