Vermont Department of Taxes          PO Box 547 Montpelier, VT 05601 0547-                                      Phone: (802) 828-2551           

                                                                                                                This form must be completed 
        VT Form                                 DECLARATION OF                                                  annually by all uncovered 
                                                                                                                employees. Employers must 
        HC 2-                          HEALTH CARE COVERAGE                                                     retain this form for 3 years.  

Employer: This form is only to be completed by employees if you offer to pay a portion of a health care plan that provides hospital and physicians 
services to at least some of your employees. You must retain all employee declaration forms together in a file for three years and be able to produce 
them in the event of an audit. 
Employer’s Legal Name (Please print) ________________________________________________________________________________________ 

Employee: Complete and sign this form and return it to your employer. The purpose of this form is to obtain information regarding your health care 
coverage. The information you provide on this form will be used solely for purposes of determining if your employer must pay Health Care Contributions 
as required under Vermont law at 32 V.S.A § 10503.  
Employee’s Full Name (Please print)  

Employee ID or Social Security Number                                              Date of Birth 

                                                                                                                
Will the employee be under the age of 18 for the entire calendar year?                             YES              NO 
If YES, stop. Please sign the bottom of the form and submit it to your employer.  
If NO, please continue to complete this form and submit it to your employer. 

Check the box beside the statement that best describes your health care coverage.  

1. My employer offers health care coverage to me.
    I have accepted the health care coverage offered and provided by my employer.

2. My employer offers health care coverage to me, and I have not accepted my employer’s coverage.
    I have health care coverage that includes hospital and physicians services from a source other than Medicaid or Vermont Health Benefit
      Exchange.
      My coverage is provided through: ___________________________________________________________________________________
    I am a full-time employee and have health care coverage as an individual through the Vermont Health Benefit Exchange.
     I have Medicaid.
     I have no health care coverage.

3. My employer does not offer health care coverage to me.
    I am a part-time employee who works fewer than 30 hours per week, and I have coverage from a source other than Medicaid that offers
      hospital and physicians services.
    I am a seasonal employee who expects to work for this employer 20 or fewer weeks during this calendar year, and I have coverage from a
      source other than Medicaid that offers hospital and physicians services.
    I have health care coverage that offers hospital and physicians services.
      My coverage is provided through:  ____________________________________________________________________________________

    I am a part-time or seasonal employee, and I do not have health care coverage  orI am covered by Medicaid.
    I have no health care coverage.

     I certify the above information is accurate and true to best of my knowledge and belief.

Employee Signature                                                                                         Date 
Note: If your health care coverage changes within the year, you must complete a new Declaration of Health Care Coverage. 

                                                                                                                             Form HC-2 
                                                                                                                          (Rev. 03/2018)