YourTrackToHealth

Application for Coverage of Common Law Husband or Wife and Statement Regarding Common Law Marriage Opens in a new window

  • This enrolls a spouse of a Common Law marriage to the medical plan for Railroad employees. This application must be accompanied by the Statement Regarding Common Law Marriage (see the documents above) and one of the following documents:
    • A lease or mortgage in both of your names
    • A vehicle registration in both of your names or
    • A copy of last year’s federal tax form 1040 showing you filed a joint tax return
  • The Statement Regarding Common Law Marriage must be completed and verified by a notary public for those couples seeking medical coverage as a husband or wife of a couple who present themselves as married by the common law marriage rules of their state.

Application for Extension of Dependent Benefits Opens in a new window
This form is the application for extension of benefits for an eligible dependent with a disabling condition.

Electronic Funds Transfer (EFT) Opens in a new window

  • EFT is a payment method that allows you to have your premium payment for GA-23111 and/or COBRA automatically deducted from your checking or savings account.

Michelle's Law Opens in a new window

  • Student Medical Leave Certification Form Instructions.

Physician’s Statement of Child’s Disabling Condition Opens in a new window

  • Your child’s physician should state the physical or mental disabling condition and the date first seen and the prognosis.

Proof of Disability Opens in a new window

  • Physician should state when disability started and when employee can return to work.
  • Return form to Railroad Enrollment Services. Address is on form.

Retirement Application Opens in a new window

  • Send application 30 days prior to retirement date to address on form.
  • Questions regarding retirement, call 1-800-842-5252.

Railroad Employees National Health and Welfare Plan Beneficiary Form Opens in a new window

  • Step 1 – Click to download form.
  • Step 2 – Print and fill the form.
  • Step 3 – Mail to the address listed on page 3 of the form.

National Railway Carriers and United Transportation Union (NRC/UTU) Health and Welfare Plan Beneficiary Form Opens in a new window

  • Step 1 – Click to download form.
  • Step 2 – Print and fill the form.
  • Step 3 – Mail to the address listed on page 3 of the form.

Statement of Child’s Unmarried Status, Residence and Dependency Opens in a new window

  • This statement is used to determine the dependency a child has on you for support to qualify the child eligible for medical coverage as your dependent under the Railroad Plan.

Supplemental Insurance Opens in a new window

  • Supplemental plans A, B, C, E or F must be applied for within four (4) months of eligibility.
  • If you do not apply within the first four (4) months, you must wait for open enrollment which occurs every November and December of even years.

Aetna SSB Claim Form Opens in a new window
This form should be used when you choose to file a claim via mail.

Trustmark SSB Claim Form Opens in a new window
This form should be used when you choose to file a claim via mail.

Trustmark Medical Authorization Form Opens in a new window
This form, when signed by the claimant, authorizes Trustmark to request and obtain relevant medical information needed to support the filed claim. It only uses information specific to the current filed claim and is subject to the same privacy controls and standards as any other medical information.



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