Declaration of Health Care Coverage Form
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Declaration of Health Care Coverage Form

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.



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 by Act 191 of the 2006 Legislature, An Act Relating to Health Care Affordability for Vermonters.


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.


Section B: Complete this section if you are NOT eligible to enroll in the Health Care plan your employer offers.


Section C: Complete this section if you are ELECTING to enroll in the Health Care plan your employer offers.

NOTE to Employee: If at some point within the next year your health care coverage changes, you are
encouraged to complete another declaration.

By the electronic signature above, I certify that information contained in this form is the truth.

Please be patient after submitting the form. You will be redirected momentarily.