Member Forms

member 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.	05/2009	44kb	164kb
VRS-3A	Name/Address Declaration For Deferred Members	01/2007	74kb	219kb
VRS-3ORP	Request for Transfer of Refund to ORP	07/2006	38kb	178kb
VRS-5	Application for Retirement	07/2009	49kb	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-9	Election of Employer for VRS Reporting	08/2005	32kb	174kb
VRS-11	Employer Certification of Involuntary Separation Under Workforce Transition Act	02/2009	37kb	126kb
VRS-11A	Employer Certification of Basic Group Life Insurance Coverage Under Workforce Transition Act	02/2009	27kb	106kb
VRS-15	Request for Income Tax Withholding	07/2005	61kb	164kb
VRS-26	Application for Purchase of Prior Service Credit	09/2008	60kb	195kb
VRS-26C	Authorization for After-Tax Payroll Deduction to Purchase Service Credit	01/2005	37kb	183kb
VRS-26E	Agreement for Salary Reduction to Purchase Service Credit	01/2005	47kb	191kb
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	01/2005	81kb	373kb
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	70kb	178kb
VRS-48	Request for Member Information Change	07/2009	29kb	150kb
VRS-57	Authorization for Direct Deposit of Monthly Benefit	07/2008	27kb	144kb
VRS-60	Request for Estimate of Retirement Benefits	06/2003	69kb	229kb
VRS-65	Election to Participate - ORP for Higher Education	05/2008	28kb	138kb
VRS-65D	Termination Certification Form- ORP for Higher Education	06/2009	31kb	110kb
VRS-65E	Termination Certification Form - Optional Retirement Plan for Political Appointees	06/2009	33kb	112kb
VRS-70	Request for Review of Membership Records	07/2003	71kb	119kb
VRS-71B	Termination Certification Form - ORP for School Superintendents	01/2009	36kb	122kb
VRS-75	ORP Health Insurance Credit Employer Certification of Service Completed only by employers certifying ORP participants.	11/2008	35kb	148kb
VRS-83	Certification of Eligibility to Participate in Virginia Supplemental Retirement Plan	01/2009	23kb	99kb
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	158kb