2024 Cleveland-Cliffs Steel LLC VEBA RETIREE HEALTHCARE ELECTION FORM Name(Required) First Last Email(Required) Enter Email Confirm Email Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth(Required)MM slash DD slash YYYY Social Security Number(Required)Enrolled in Medicare(Required) Yes No Medicare ID# Part A Effective DateMM slash DD slash YYYY Part B Effective DateMM slash DD slash YYYY Program Disclaimer 1(Required)If the election to enroll in the Cleveland-Cliffs Steel LLC VEBA Retiree Healthcare program effective 1/1/2024, I understand that I will not qualify for the Medicare Part B Reimbursement from 1/1/2024-12/31/2024, but I may change my election for the calendar year 2025. I wish to enroll in Premier Plan which is $90 per month for both Medical and Rx Benefits for January 1, 2024. I wish to enroll in Plus Plan which is $40 per month for both Medical and Rx Benefits for January 1, 2024. I wish to enroll in Basic Enhanced Plan which is $5 per month for both Medical and Rx Benefits for January 1, 2024. I do NOT elect to enroll in any MAPD plans for January 1, 2024 and would like to remain eligible for the Medicare Part B Reimbursement for 2024. I acknowledge that I cannot change this election until January 1, 2025. YOU MUST SELECT ONE OF THE BOXES ABOVE I have received, read, and understood the information explaining the Cleveland-Cliffs Steel LLC VEBA options. I request membership in the plan that I have elected on this form for which I am eligible. I understand that if I enroll in the Cleveland-Cliffs Steel LLC VEBA Medicare Advantage Plans with Prescription Drugs which are listed above, by signing this form, I am making a binding election that I will not be able to change my election until 1/1/2025. I understand that if I do not return this election form by December 10, 2023, I will NOT be enrolled in the Anthem MAPD Plan with Prescription drugs for 1/1/2024, but will remain eligible for the Medicare Part B Reimbursement Benefit. I also understand that I will have another opportunity in the Fall of 2024 to make an additional selection into either Retiree Healthcare or the Medicare Part B Reimbursement which would be effective January 1, 2025. Retiree Signature(Required)Consent(Required) By checking this form and providing my signature, I attest that all information is true and accurate to the best of my knowledge.(Required)My spouse is enrolled in Medicare and wishes to enroll in the program. My spouse is enrolled in Medicare and wishes to enroll in the program.Spouse ApplicationComplete this section if you are the spouse of a living retiree.Spouse Name(Required) First Last Spouse PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Spouse Date of Birth(Required)MM slash DD slash YYYY Spouse Social Security NumberEnrolled in Medicare Yes No Spouse Medicare ID# Part A Effective DateMM slash DD slash YYYY Part B Effective DateMM slash DD slash YYYY Program Disclaimer(Required)If the election to enroll in the Cleveland-Cliffs Steel LLC VEBA Retiree Healthcare program effective 1/1/2024, I understand that I will not qualify for the Medicare Part B Reimbursement from 1/1/2024-12/31/2024, but I may change my election for the calendar year 2024. I wish to enroll in Premier Plan â which is $90 per month for both Medical and Rx Benefits for January 1, 2024. I wish to enroll in Plus Plan â which is $40 per month for both Medical and Rx Benefits for January 1, 2024. I wish to enroll in Basic (Formerly Plan C) â which is $0 per month for both Medical and Rx Benefits for January 1, 2024. I do NOT elect to enroll in any MAPD plans for January 1, 2023 and would like to remain eligible for the Medicare Part B Reimbursement for 2024. I acknowledge that I cannot change this election until January 1, 2025. YOU MUST SELECT ONE OF THE BOXES ABOVE I have received, read, and understood the information explaining the Cleveland-Cliffs Steel LLC VEBA options. I request membership in the plan that I have elected on this form for which I am eligible. I understand that if I enroll in the Cleveland-Cliffs Steel LLC VEBA Medicare Advantage Plans with Prescription Drugs which are listed above, by signing this form, I am making a binding election that I will not be able to change my election until 1/1/2025. I understand that if I do not return this election form by December 10, 2023, I will NOT be enrolled in the Anthem MAPD Plan with Prescription drugs for 1/1/2024, but will remain eligible for the Medicare Part B Reimbursement Benefit. I also understand that I will have another opportunity in the Fall of 2024 to make an additional selection into either Retiree Healthcare or the Medicare Part B Reimbursement which would be effective January 1, 2025. Spouse Signature(Required)Please enter your spouse’s signature.
