Document qmpbEYag7EEZNQ6OgEMbQaDjG

MEDICARE NATIONWIDE MUTUAL INSURANCE COMPANY MEDICARE OPERATIONS P.O. BOX 16562 COLUMBUS. OHIO 43216 NATIONWIDE INSURANCE Nationwide is on your side EMPLOYER CERTIFICATION FORM Beneficiary Name: Health Insurance Number:.....^ A Complete and check the applicable section. Q SECTION I: Pursuant to 42 USC 1395ytb) (4), the undersigned, on behalf of, does hereby certify that the Medicare beneficiary listed above is an employee of said firm for purposes of the Medicare Secondary Payer Disability provision.! further certify that ou r employer group health plan must be considered a Large Croup Health Plan as defined in Section 5000 of the Internal Revenue Code. pod SECTION- II: Pursuant to 42 USC 1395y(b) (4), the undersigned, on behalf of Upiroyal Chemical Company, Inc, does hereby certify that the Medicare beneficiary listed above isnot an employee of said firm in any manner or for any purpose, effective 7-01-82 (Date of Disability j specifically certify the following: R& t ir 8ms nt) 1. The beneficiary is not receiving payments that are subject to taxes under the Federal Insurance Contributions Act (FICA) or that would be subject to such taxes except that our company is not required to pay such taxes under the Internal Revenue Code. 2. The beneficiary is not termed an employee under any State or Federal law or in accordance with a court decision. 3. We do not pay the same taxes for the beneficiary that we pay for actively working employees. 4. The beneficiary neither continues to accrue vacation time, nor does the beneficiary receive vacation pay. 5. The beneficiary does not participate in an employer's benefit plan in which only employees may participate. . 6. The beneficiary does not have rights to return to duty if his/her condition improves. 7. The beneficiary does not continue to accrue sick leave. 8. The beneficiary is not considered an employee in any other manner. SECTION HI: Pursuant to 42 USC 1395y(b) (4), the undersigned, on behalf of, does hereby certify that the group health plan of said firm does not qualify as a Large Croup Health Plan as defined in Section 5000 of the Internal Revenue Code. nATT, April 27, 1990 Uniroyal Chemical Company, Inc. ADDRESS' ^20 Fairport-Nursery Road Painesville, OH 44077 U. Industrial Relaions Assistant MED 664 UNIR0000292