Your limited-purpose coverage election will remain in force until you make a change. You can make one limited-purpose coverage election change per
calendar year. For example, if you turn on limited-purpose coverage in April, you must wait until the following January to turn off limited-purpose coverage
and change back to full coverage. More than one change during a calendar year may be allowed for certain life events. For instance, you may be allowed
to make a change within 30 days of losing other health coverage (due to separation of employment or other reason) or adding a legal spouse or dependent
through marriage, birth, or adoption. Please be aware, any auto withdrawal from your account for qualied insurance premiums will stop immediately with
your limited-purpose coverage start date. If you have more than one claims-eligible participant account, this election or revocation will apply to all of your
claims-eligible participant accounts.
By signing below, you hereby elect or revoke limited-purpose VEBA Plan coverage as described above for you and your legal spouse and dependent(s), if any.
This election of limited-purpose VEBA Plan coverage shall be effective from the first of the month following the Plan’s receipt of this completed form and shall
continue until further notice. Submitting this completed form does not guarantee your eligibility to contribute to an HSA. Your eligibility to contribute to an HSA
is determined by several factors. The VEBA Plan and Trust is not responsible for determining your eligibility to contribute to an HSA or your maximum annual
HSA contribution amount. You should talk to a tax or benefits professional as special rules apply. The VEBA Plan and Trust does not endorse, approve nor
in any manner make determination regarding whether any other program in fact qualifies as an HSA or is suitable for any participant.
Limited-purpose VEBA Plan coverage covers only the types of expenses listed below. All other expenses
incurred while coverage is limited, including qualified insurance premiums, are not covered.
HSA contribution eligibility: Tobecomeeligibletomakeorreceivecontributionstoahealthsavingsaccount(HSA),youmustfirstlimityourVEBA
Medicare coordination of benefits: Ifyouarestillworkingandeitheryou,yourlegalspouse,oradependentareonMedicare,youwillberequired
VEBAPlancoverage.If you’re separated from your employer,contacttheVEBAPlanwithyourseparationdatetoavoidproblemsreceiving
Medicarebenefits.If you’re still workingandyouelectlimited-purposeVEBAPlancoverage,Medicarewillprovidebenefitswithoutrequiring
LIMITED-PURPOSE COVERAGE ELECTION
REQUIRED AUTHORIZING PARTICIPANT SIGNATURE
Your handwritten signature is required; e-signatures are not acceptable.
PARTICIPANT ACCOUNT CONTACT INFORMATION
ACCOUNT NUMBER or SSN DATE OF BIRTH MM / DD / YYYY
FIRST NAME M.I.
NAME EXACTLY AS IT APPEARS ON SOCIAL SECURITY CARD or MEDICARE CARD
MEDICARE ID NUMBER (HICN) PART A EFFECTIVE DATE PART B EFFECTIVE DATE
DATE OF SEPARATION OR RETIREMENT MM / DD / YYYY
MAILING ADDRESS CITY STATE ZIP
AREA CODE and PHONE NUMBER EMAIL ADDRESS (use home or personal email address)
PARTICIPANT SIGNATURE DATE MM / DD / YYYY PHONE NUMBER WHERE I CAN BE REACHED
Check the appropriate box to TURN ON or TURN OFF limited-purpose VEBA Plan coverage.
Your election will become effective on the rst of the month following the Plan’s receipt of this completed form.
Turn OFF limited-purpose coverage
VP22 (12/14 PRC)
1-888-828-4953 | email@example.com | veba.org
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