Member Forms

member Forms
Form #	Description	Non-fill	Fillable
N/A	Minnesota Life/VRS Life Insurance Forms Page
N/A	VRS Certificate of Life Insurance	322kb
T-20530	State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants	69kb
VSDP-2	College and University Enrollment Form	244kb	213kb
VRS-2	Designation of Beneficiary To designate more than 4 beneficiaries, a continuation form, the VRS-2A, is also required.	60kb	219kb
VRS-2A	Designation of Beneficiary - Continuation	58kb	194kb
VRS-3	Request for Refund You MUST read the IRS 402(f) Special Tax Notice before filling out this form.	57kb	171kb
VRS-3A	Name/Address Declaration For Deferred Members	74kb	219kb
VRS-3ORP	Request for Transfer of Refund to ORP	38kb	178kb
VRS-5	Application for Service Retirement	58kb	239kb
VRS-5A	VSDP Conversion of Disability Credits	37kb	123kb
VRS-6	Application for Disability Retirement	56kb	239kb
VRS-6A	Explanation of Disability	30kb	166kb
VRS-6B	Physicians Report	96kb	243kb
VRS-6C	Request for Estimate of Disability Retirement Benefits	96kb	248kb
VRS-6D	Employer Information for Disability Application	36kb	182kb
VRS-9	Election of Employer for VRS Reporting	32kb	174kb
VRS-11	Employer Certification of Involuntary Separation Under Workforce Transition Act of 1995	58kb	237kb
VRS-11A	Employer Certification of Group Life Insurance Coverage Under Workforce Transition Act of 1995	36kb	191kb
VRS-15	Request for Income Tax Withholding	61kb	164kb
VRS-26	Application for Purchase of Prior Service Credit	78kb	233kb
VRS-26C	Authorization for After-Tax Payroll Deduction to Purchase Service Credit	37kb	183kb
VRS-26E	Agreement for Salary Reduction to Purchase Service Credit	47kb	191kb
VRS-26F	Employer Certification of Accumulated Sick Leave Eligible for Conversion to Service Credit	38kb	185kb
VRS-26G	Request for Trustee-to-Trustee Transfer or Rollover of Funds to Purchase Service Credit	81kb	373kb
VRS-27	Waiver of Life Insurance Coverage	82kb	171kb
VRS-31	Accidental Dismemberment and Loss of Sight	17kb
VRS-32	Group Life Evidence of Insurability		90kb
VRS-35E	Conversion of Group Life Insurance Enrollment	186kb
VRS-37	Absolute assignment of Group Life Insurance	44kb
VRS-38	Assignees Change of Beneficiary	46kb
VRS-39	Application for Optional Life Insurance	79kb
VRS-39A	Request for Change Under Optional Group Life Insurance Plan		54kb
VRS-39R	Retiree Optional Life Continuation	45kb
VRS-45	Request for Health Insurance Credit Retired participants who do not have premiums deducted from their VRS monthly benefit must complete this form.	75kb	169kb
VRS-48	Request for Member Information Change	32kb	166kb
VRS-57	Authorization for Direct Deposit of Monthly Benefit	44kb	130kb
VRS-60	Request for Estimate of Service Retirement Benefits	69kb	229kb
VRS-65	Election to Participate - ORP for Higher Education	28kb	138kb
VRS-65D	Termination Certification Form- ORP for Higher Education	67kb	213kb
VRS-65E	Termination Certification Form - Optional Retirement Plan for Political Appointees	74kb	159kb
VRS-70	Request for Review of Membership Records	71kb	119kb
VRS-71B	Termination Certification Form - ORP for School Superintendents	70kb	220kb
VRS-75	ORP Health Insurance Credit Employer Certification of Service Completed only by employers certifying ORP participants.	62kb	156kb
VRS-83	Certification of Eligibility to Participate in Virginia Supplemental Retirement Plan	30kb	174kb
VRS-170	VSDP Long-Term Care Plan Authorization of Coverage Retention	24kb	136kb
VRS-171	VSDP Long-Term Care Plan Protection Against Unintentional Lapse	21kb	130kb
VRS-900	Authorization to Discuss VRS Account Information	36kb	145kb
VRS-901	VRS Durable Power of Attorney	54kb	163kb