Read Benefit_Trust_Verification_Form.pdf text version

ArcelorMittal USA Inc. VEBA Retiree Drug Plan c/o Administrator 25111 Miles Rd, Suite B, Cleveland, OH 44128 1-877-474-8322

ARCELORMITTAL USA VEBA Benefit Trust Verification Form


1. Complete the information below 2. Please print clearly 3. Attach proper documentation to this form which is described on the enclosed letter

Information Requested

Retiree Social Security Number: Retiree First Name: Retiree Last Name: Retiree Address 1: Retiree Phone Number : Retiree City: Retiree State: Retiree Zip Code: Retiree Date of Birth Retiree Date of Death Retiree Retirement Date: Plant Retiree Employed At: Plant Location Spouse First Name: Spouse Last Name: Spouse Social Security Number: Spouse Date of Birth: Were you enrolled in Retiree Healthcare Marriage Date:

Retiree Information

Signature and Relationship of Person Provided Above Information


ArcelorMittal USA VEBA 25111 Miles Road, Suite B Cleveland, OH 44128 Toll Free: (877) 474-8322 Dear Retiree: The current collective bargaining agreement between ArcelorMittal Steel USA and the United Steelworkers (USW) established a Benefit Trust for the benefit of former USWA-represented retirees and surviving spouses who worked for Acme Steel, LTV Steel, Bethlehem Steel, or Georgetown Steel and lost their negotiated health care benefits as a result of the bankruptcy and liquidation of these companies. Under the agreement, ArcelorMittal will make periodic contributions to the Benefit Trust. The beneficiaries of the Trust include retirees and surviving spouses (and their eligible dependents) who retired on or before the following dates and were eligible for retiree health care benefits at retirement: Acme Steel LTV Steel Bethlehem Steel Georgetown Steel June 1, 2002 March 31, 2002 May 8, 2003 October 20, 2003

In addition, if a retiree died after their applicable termination date, the surviving spouse may also be a beneficiary. In order for you to receive the enrollment package for the Benefit Trust, it is important that you complete the enclosed Benefit Trust Verification Form and return it to the VEBA Administrator along with one other form of back-up documentation, such as: 1099R from PBGC, (if you do not have these documents, you can call the PBGC at 1-800-400-7242) Written documentation proving that you were a member of the United Steelworkers and eligible for retiree medical benefits at time of retirement A copy of your retiree medical benefits that were canceled in 2002, 2003, or 2004

Please make sure that the Verification Form and the documentation is in the enclosed return envelope. Once we are able to determine your eligibility, you will receive a letter based on that determination and additional information if it applies. If you have any questions regarding this notice and the enclosed Benefit Trust Verification Form, please contact the Administrator by calling, tollfree, 1-877-474-8322. The Administrator will be available to assist you Monday through Friday, from 8:00am ­ 5:00pm, Eastern Standard Time. Sincerely, ArcelorMittal USA VEBA

Updated 12/23/09


2 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate


You might also be interested in

Microsoft Word - ArcelotMittalSummary925.doc