> Forms

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		322kb
T-20637	State Health Benefits Program Enrollment Form For Retirees, Survivors And LTD Participants		88kb
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.	07/2009	42kb	169kb
VRS-2A	Designation of Beneficiary - Continuation	07/2009	30kb	153kb
VRS-3	Request for Refund You MUST read the IRS 402(f) Special Tax Notice before filling out this form.	05/2010	37kb	215kb
VRS-3A	Name/Address Declaration For Deferred Members	01/2007	74kb	219kb
VRS-3ORP	Request for Transfer of Refund to Optional Retirement Plan	07/2006	38kb	178kb
VRS-3S	Signature Authorization Member Contribution Refund	08/2008	44kb	141kb
VRS-5	Application for Retirement	05/2010	50kb	201kb
VRS-5A	VSDP Conversion of Disability Credits	07/2008	27kb	139kb
VRS-6	Application for Disability Retirement	07/2009	48kb	203kb
VRS-6A	Explanation of Disability	04/2008	30kb	166kb
VRS-6B	Physician's Report	11/2008	51kb	228kb
VRS-6C	Request for Estimate of Disability Retirement Benefits	07/2003	96kb	248kb
VRS-6D	Employer Information for Disability Application	11/2008	23kb	133kb
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	04/2009	19kb	94kb
VRS-9	Election of Employer for VRS Reporting	08/2005	32kb	174kb
VRS-11	Employer Certification of Involuntary Separation Under the Workforce Transition Act	07/2010	29kb	38kb
VRS-11A	Employer Certification of Basic Group Life Insurance Coverage Under Workforce Transition Act	02/2009	27kb	106kb
VRS-11B	Employer Certification of Involuntary Separation Under the Transitional Benefits Program	07/2010	28kb	133kb
VRS-11C	Employer Certification of VRS Basic Group Life Insurance Coverage Under the Transitional Benefits Program	05/2010	23kb	126kb
VRS-15	Request for Income Tax Withholding	07/2005	61kb	164kb
VRS-26	Application for Purchase of Prior Service Credit	07/2010	42kb	162kb
VRS-26C	Authorization for After-Tax Payroll Deduction to Purchase Service Credit	07/2010	19kb	122kb
VRS-26E	Agreement for Salary Reduction to Purchase Service Credit	07/2010	25kb	128kb
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	12/2003	82kb	171kb
VRS-31	Accidental Dismemberment and Loss of Sight	06/1999	17kb
VRS-32	Group Life Evidence of Insurability	02/2006	90kb
VRS-35E	Conversion of Group Life Insurance Enrollment	09/2008	186kb
VRS-37	Absolute Assignment of Group Life Insurance	02/2008	44kb
VRS-38	Assignees Change of Beneficiary	02/2008	46kb
VRS-39	Application for Optional Life Insurance	12/2006	79kb
VRS-39A	Request for Change Under Optional Group Life Insurance Plan	04/2004		54kb
VRS-39R	Retiree Optional Life Continuation	05/2001	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.	11/2008	58kb	162kb
VRS-48	Request for Member Information Change	07/2009	29kb	150kb
VRS-49	Change to Certification for Retirement	06/2010	22kb	129kb
VRS-52	Monthly Contribution Worksheet	07/2005	53kb	66kb
VRS-57	Authorization for Direct Deposit of Monthly Benefit	07/2008	27kb	144kb
VRS-58	Name/Address Declaration For Retirees	12/2007	28kb	34kb
VRS-60	Request for Estimate of Retirement Benefits	07/2010	38kb	148kb
VRS-65	Election to Participate - Optional Retirement Plan for Higher Education	06/2010	35kb	144kb
VRS-65B	Certification of Eligibility to Participate in Optional Retirement Plan for Political Appointees	06/2009	23kb	101kb
VRS-65D	Termination Certification Form- Optional Retirement Plan for Higher Education	06/2009	31kb	110kb
VRS-65E	Termination Certification Form - Optional Retirement Plan for Political Appointees	06/2009	33kb	112kb
VRS-67	Authorization of Employer Contacts	05/2008	45kb	208kb
VRS-67A	Employer Certification of Authority	05/2008	35kb	162kb
VRS-70	Request for Review of Membership Records	07/2003	71kb	119kb
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	08/2009	29kb	107kb
VRS-75	Optional Retirement Plan Health Insurance Credit Employer Certification of Service Completed only by employers certifying Optional Retirement Plan participants.	11/2008	35kb	148kb
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.	11/2008	34kb	73kb
VRS-77	Certification of Hazardous Duty	07/2009	18kb	90kb
VRS-78	Authorization to Deduct Insurance Premiums and Application for Health Insurance Credit Completed only by employers for non-state participants.	12/2006	46kb	138kb
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	05/2010	20kb	123kb
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-900	Authorization to Discuss VRS Account Information	04/2009	31kb	145kb
VRS-901	VRS Durable Power of Attorney	04/2009	60kb	168kb
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