Apply for the Medicare Part B Reimbursement

2015 Medicare part B Premium Reimbursement
BENEFIT APPLICATION FORM
Printable Part B Reimbursement Benefit Application RETIREE APPLICATION (Complete this Section if you are a Retiree or the Surviving Spouse of a deceased Retiree) If this is your first time completing the Reimbursement Application, please complete the paper copy sent to you and enclose a copy of your Medicare card.

*required

Name*:
Phone*:
Address*:
City*:
State*:
Zip*:
Email Address*:
Social Security #*:
Date of Birth*:	Month/Day/Year
Beneficiary* (Retiree or Surviving Spouse) Signature:	Yes (Sign this by checking the check box and filling in your initials.)

If your spouse is enrolled in Medicare and wishes to apply for a Reimbursement Benefit, your spouse must complete and digitally sign the following Spouse Application. In order to be eligible, your date of marriage must have been before your healthcare benefits were terminated on one of the following dates.

LTV Steel:	March 31, 2002	Georgetown Steel:	October 20,2003
Bethlehem Steel:	May 8, 2003	Acme Metals:	June 1, 2002
Weirton Steel:	May 17, 2004

SPOUSE APPLICATION (Complete this Section if you are the Spouse of a living Retiree)

Spouse Name:
Phone:
Address:
City:
State:
Zip:
Email Address:
Social Security #:
Date of Birth:	Month/Day/Year
Date of Marriage:
Spouse Signature:	Yes (Sign this by checking the check box and filling in your initials.)

I attest that all information is truthful to the best of my knowledge.

QUESTIONS?
Call the VEBA Toll-Free at 1-877-474-8322