VT Health Declaration Reform

Vermont Health Declaration Reform
Health Declaration Reform

VT FORM HC-2
The purpose of this form is to obtain information regarding your health care coverage. The information you provide on this form will be used solely for purposes of determining if your employer must pay Health Care Contributions as required under Vermont law at 32 V.S.A § 10503.
Employees Full Name*
Date of Birth*

MonthDayYear
Date
Yes (If yes, please sign and date. No selection required below.)No (If no, please select ONE option below.)
I am a part-time employee who works fewer than 30 hours per week, and I have coverage from a source other than Medicaid that offers hospital and physician services.I am a seaonal employee who expects to work for this employer 20 or fewer weeks during this calendar year, and I have coverage from a source other than Medicaid that offers hospital and physician services.I have healthcare that offers hospital and physician services.I am a part-time or seasonal employee, and do not have health care coverage or I am covered by Medicaid.I have no health care coverage.
I certify the above information is accurate and true to the best of my knowledge and belief.
Today's Date*

MonthDayYear
Date
I agree
Should be Empty:

Vermont Health Declaration Reform