Social Security Credible Insurance Form

Request for employment information section a.

Social security credible insurance form. Form approved omb no. The information provided in section b is the evidence of ghp or lghp coverage. Employer s address city state zip code 4. The applicant completes section a and the employer the ghp or lghp completes section b of the form.

The form you are looking for is not available online. Or contact your local social security office. Up to date information online form is always the latest edition. An employer with small group insurance is a company with less than 20 employees.

Form cms l564 is an employment information form from the social security administration ssa. Small group plans may not be considered creditable coverage under medicare. You may access the online certificate of coverage service at opts ssa gov. If you would like instructions or require assistance with the use of the online forms please contact the social security administration s office of.

Many forms must be completed only by a social security representative. To be completed by individual signing up for medicare part b medical insurance 1. A certificate of coverage is an official form issued by the social security administration ssa or an authorized agency of an agreement country to certify that the worker named on the form is subject to social security coverage in the issuing country and exempt from coverage in the other country. Please call us at 1 800 772 1213 tty 1 800 325 0778 monday through friday between 8 a m.

Date 3. If you were first employed before october 1 1982 you can either. The same is true when you re on your spouse s large employer group health plan. Service performed on or after january 1 1957 normally creditable for social security benefits at age 62.

A deposit may be due to credit the service. One portion is completed by you and the other is completed by your employer or your spouse s employer. If the company you work for has more than 20 employees you have creditable coverage for medicare. Applicant s social security number 6.

Make a deposit for post 1956 military service thereby avoiding a reduction in your annuity at age 62 or. It s used in conjunction with form cms 40b when you apply for medicare part b during a special enrollment period sep. Form cms l564 request for employment information the form cms l564 has two sections.