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Forms
Form #	Description	Last Updated	Non-fill	Fillable
N/A	Minnesota Life/VRS Life Insurance Forms Page
N/A	VRS Certificate of Life Insurance	07/2009	173kb
T-20879	State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants	4/2013	98kb
VSDP-2	College and University Opt-Out Form	09/2011	22kb	146kb
VRS-2	Designation of Beneficiary To designate more than 3 beneficiaries, a continuation form, the VRS-2A, is also required.	04/2011	51kb	179kb
VRS-2A	Designation of Beneficiary - Continuation	02/2011	29kb	48kb
VRS-3	Request for Refund You MUST read the IRS 402(f) Special Tax Notice before filling out this form.	12/2011	47kb	183kb
VRS-3A	Name and Address Declaration For Deferred Members	02/2011	22kb	28kb
VRS-3ORP	Request for Plan-to-Plan Transfer to ORP	02/2011	24kb	33kb
VRS-3S	Signature Authorization Member Contribution Refund	11/2012	37kb	142kb
VRS-5	Application for Retirement	12/2012	58kb	227kb
VRS-6	Application for Disability Retirement	12/2012	58kb	236kb
VRS-6A	Explanation of Disability	12/2012	27kb	156kb
VRS-6B	Physician's Report	02/2011	31kb	93kb
VRS-6C	Request for Estimate of Disability Retirement Benefits	02/2011	23kb	33kb
VRS-6D	Employer Information for Disability Application	02/2011	21kb	26kb
VRS-6E	Certification of Alternate Employment for Disability Retiree for Political Subdivision Hazardous Duty Employees	08/2012	57kb	264kb
VRS-7	Request for Termination of Monthly Benefit	07/2004	32kb	176kb
VRS-7ORP	Notice of Return to Covered Employment Optional Retirement Plan Retiree	11/2012	40kb	217kb
VRS-8	Certification of Exception from General Early Retirement Provisions	07/2011	22kb	124kb
VRS-11	Employer Certification of Involuntary Separation Under the Workforce Transition Act	07/2011	34kb	43kb
VRS-11A	Employer Certification of Basic Group Life Insurance Coverage Under Workforce Transition Act	02/2011	27kb	29kb
VRS-11B	Employer Certification of Involuntary Separation Under the Transitional Benefits Program	02/2011	33kb	38kb
VRS-11C	Employer Certification of VRS Basic Group Life Insurance Coverage Under the Transitional Benefits Program	02/2011	27kb	29kb
VRS-15	Request for Income Tax Withholding	02/2011	30kb	45kb
VRS-26	Application for Purchase of Prior Service Credit	03/2013	80kb	244kb
VRS-26C	Authorization for After-Tax Payroll Deduction to Purchase Service Credit	03/2013	33kb	210kb
VRS-26E	Agreement for Salary Reduction to Purchase Service Credit	03/2013	37kb	217kb
VRS-27	Waiver of Life Insurance Coverage	02/2011	21kb	23kb
VRS-31	Accidental Dismemberment and Loss of Sight	06/1999	17kb
VRS-32	Group Life Evidence of Insurability	02/2011		344kb
VRS-35E	Conversion of Group Life Insurance Enrollment	02/2011		582kb
VRS-37	Absolute Assignment of Group Life Insurance	02/2011		314kb
VRS-38	Assignees Change of Beneficiary	02/2011		352kb
VRS-39	Application for Optional Life Insurance	02/2011		325kb
VRS-39A	Request for Change Under Optional Group Life Insurance Plan	02/2011		334kb
VRS-39R	Retiree Optional Life Continuation	02/2011		299kb
VRS-45	Request for Health Insurance Credit Retired participants who do not have premiums deducted from their VRS monthly benefit must complete this form.	02/2011	62kb	76kb
VRS-48	Request for Member Information Change	03/2013	43kb	219kb
VRS-49	Change to Certification for Retirement	02/2011	22kb	29kb
VRS-57	Authorization for Direct Deposit of Monthly Benefit	02/2011	22kb	31kb
VRS-58	Name and Address Declaration For Retirees	03/2013	40kb	252kb
VRS-60	Request for Estimate of Retirement Benefits	03/2013	50kb	167kb
VRS-61	Notification of Electronic Payment Information	12/2012	37kb	157kb
VRS-65	Election to Participate - Optional Retirement Plan for Higher Education	11/2012	40kb	230kb
VRS-65B	Certification of Eligibility to Participate in Optional Retirement Plan for Political Appointees	02/2011	23kb	30kb
VRS-65D	Termination Certification Form- Optional Retirement Plan for Higher Education	04/2013	75kb	238kb
VRS-65E	Termination Certification Form - Optional Retirement Plan for Political Appointees	04/2013	77kb	172kb
VRS-67A	Authorization of Administrative Contacts	01/2013	37kb	54kb
VRS-70	Request for Review of Membership Records	02/2011	21kb	29kb
VRS-71B	Termination Certification Form - Optional Retirement Plan for School Superintendents	04/2013	74kb	239kb
VRS-75	Optional Retirement Plan Health Insurance Credit Employer Certification of Service Completed only by employers certifying Optional Retirement Plan participants.	07/2012	33kb	150kb
VRS-76	Certification of Employment for Health Insurance Credit Eligibility Completed only by employers certifying general registrars, local officers, employees of these referenced positions and local social service employees.	02/2011	33kb	54kb
VRS-77	Certification of Hazardous Duty	02/2011	22kb	24kb
VRS-78	Authorization to Deduct Insurance Premiums and Application for Health Insurance Credit Completed only by employers for non-state participants.	04/2011	27kb	133kb
VRS-83	Certification of Eligibility to Participate in Virginia Supplemental Retirement Plan	01/2009	23kb	99kb
VRS-160A	Certification of Non-Participation of Critical Shortage Teachers and Administrators	04/2013	26kb	144kb
VRS-170	VSDP Long-Term Care Plan Authorization of Coverage Retention	08/2008	27kb	140kb
VRS-171	VSDP Long-Term Care Plan Protection Against Unintentional Lapse	08/2008	26kb	130kb
VRS-180	Employer Request for Forfeiture of Member Benefits	12/2011	36kb	166kb
VRS-900	Authorization to Discuss VRS Account Information	02/2011	28kb	33kb
VRS-901	VRS Durable Power of Attorney	07/2012	43kb	47kb