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Forms

--- Show Me --- All Forms All Employer Forms Disability Retirement Forms Health Insurance Credit Forms Group Life Insurance Forms Miscellaneous Forms Non-VRS Forms Optional Retirement Forms Payroll Forms Purchase of Prior Service Forms Service Retirement Forms Virginia Sickness & Disability Forms (state only) All Member Forms Disability Retirement Forms Group Life Insurance Forms Miscellaneous Forms Non-VRS Forms Optional Retirement Forms Purchase of Prior Service Forms Service Retirement Forms Virginia Sickness & Disability Forms (state only) All Retiree Forms Update Your Information Forms Life & Health Insurance Forms

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-20802	State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants	10/2011	120kb
VSDP-2	College and University Opt-Out Form	09/2011	22kb	140kb
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	02/2011	22kb	125kb
VRS-5	Application for Retirement	12/2011	125kb	271kb
VRS-5A	VSDP Conversion of Disability Credits	07/2008	27kb	139kb
VRS-6	Application for Disability Retirement	02/2011	53kb	109kb
VRS-6A	Explanation of Disability	02/2011	27kb	47kb
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-7	Request for Termination of Monthly Benefit	07/2004	32kb	176kb
VRS-7ORP	Notice of Return to Covered Employment Optional Retirement Plan Retiree	01/2010	22kb	127kb
VRS-8	Certification of Exception from General Early Retirement Provisions	07/2011	22kb	124kb
VRS-9	Election of Employer for VRS Reporting	08/2005	32kb	174kb
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	10/2011	46kb	234kb
VRS-26C	Authorization for After-Tax Payroll Deduction to Purchase Service Credit	01/2011	38kb	196kb
VRS-26E	Agreement for Salary Reduction to Purchase Service Credit	01/2011	56kb	205kb
VRS-26F	Employer Certification of Accumulated Sick Leave Eligible for Conversion to Service Credit	07/2003	38kb	185kb
VRS-26G	Request for Trustee-to-Trustee Transfer or Rollover of Funds to Purchase Service Credit	07/2010	41kb	148kb
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	90kb
VRS-35E	Conversion of Group Life Insurance Enrollment	02/2011	186kb
VRS-37	Absolute Assignment of Group Life Insurance	02/2011	44kb
VRS-38	Assignees Change of Beneficiary	02/2011	46kb
VRS-39	Application for Optional Life Insurance	02/2011	79kb
VRS-39A	Request for Change Under Optional Group Life Insurance Plan	02/2011	93kb
VRS-39R	Retiree Optional Life Continuation	02/2011	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.	02/2011	62kb	76kb
FBMC0509	Commonwealth of Virginia Voluntary Group Long Term Care - Post-Tax Salary Deduction Authorization for State Employees	05/2009	135kb
VRS-48	Request for Member Information Change	07/2009	29kb	150kb
VRS-49	Change to Certification for Retirement	02/2011	22kb	29kb
VRS-52	Monthly Contribution Worksheet	07/2005	53kb	66kb
VRS-57	Authorization for Direct Deposit of Monthly Benefit	02/2011	22kb	31kb
VRS-58	Name and Address Declaration For Retirees	02/2011	21kb	27kb
VRS-60	Request for Estimate of Retirement Benefits	12/2011	44kb	182kb
VRS-65	Election to Participate - Optional Retirement Plan for Higher Education	10/2011	37kb	173kb
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	10/2011	37kb	182kb
VRS-65E	Termination Certification Form - Optional Retirement Plan for Political Appointees	07/2011	75kb	148kb
VRS-67	Authorization of Employer Contacts	07/2011	50kb	201kb
VRS-67A	Employer Certification of Authority	07/2011	49kb	170kb
VRS-70	Request for Review of Membership Records	02/2011	21kb	29kb
VRS-71A	Certification of Eligibility to Participate in Optional Retirement Plan for School Superintendents	08/2009	18kb	87kb
VRS-71B	Termination Certification Form - Optional Retirement Plan for School Superintendents	07/2011	38kb	148kb
VRS-75	Optional Retirement Plan Health Insurance Credit Employer Certification of Service Completed only by employers certifying Optional Retirement Plan participants.	04/2011	32kb	145kb
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-160	Certification of Eligibility for Critical Shortage Teachers and Administrators	05/2010	30kb	140kb
VRS-160A	Certification of Non-Participation of Critical Shortage Teachers and Administrators	02/2011	26kb	29kb
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	02/2011	43kb	48kb
VRS-1500	Monthly Membership Report	07/2005	49kb	203kb
VRS-1500A	New Member Enrollment	06/2008	22kb	149kb
VRS-1501	Error Adjustment Report	07/2008	56kb	219kb
VRS-1502	Certification of Service Not Reported by Employer	03/2006	34kb	198kb

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