Enroll me in the VEBA Rx Plan!

ArcelorMittal USA Voluntary Employee Beneficiary Association
ENROLLMENT FORM
Please complete 30 days prior to the Requested Enrollment Date

BENEFICIARY INFORMATION *required

Name*:
Phone*:
Address*:
City*:
State*:
Zip*:
Social Security #*:
Date of Birth*:	Month/Day/Year
Enrolled in Medicare?	Yes No
Medicare ID #
Requested Enrollment Date*:	Month/Day/Year

SPOUSE AND DEPENDENT INFORMATION

Spouse Name:
Social Security #:
Date of Birth:	Month/Day/Year
Date of Marriage:
Spouse Enrolled in Medicare?	Yes No
Spouse Medicare ID #
Dependent Child(ren):	Yes Check if you wish to enroll your dependent child(ren). A Dependent Child Enrollment Form will be mailed to you.
Signature of Applicant*:	Yes (Sign this by checking the check box and filling in your initials.)

I apply for enrollment in the ArcelorMittal USA VEBA Prescription Drug Program.

Monthly Contributions:
$10.00 for Retiree or Surviving Spouse
$20.00 for Retireee and Dependent Spouse

DO NOT SEND PAYMENT
YOU WILL BE BILLED

If you wish to add a dependent(s) please call our office at 1-877-474-8322