ArcelorMittal USA VEBA
ArcelorMittal USA VEBA

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