Forms - HEALTH, DENTAL AND VRS FORMS
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HEALTH AND DENTAL INSURANCE INFORMATION AND FORMS FOR RETIREE'S ELIGIBLE FOR MEDICARE B
The Hartford Life & Accident Insurance Company & Express Scripts, Inc.
- Group Retiree Insurance Plan Summary of Coverage (AGP-3844)
- Senior Medical Insurance Plan Summary of Coverage (AGP-3189)
- Stafford County Public Schools - Medicare Part D Prescription Drug Benefits Provided by Express Scripts - January 1, 2015 - December 31, 2015
Enrollment Forms- Group Retiree Health Insurance Plan Enrollment Form (AGP-3844)
- Medicare Prescription Drug Plan Individual Enrollment Form
- Anthem Dental Insurance Application
- Dominion Dental 707X Plan Application
HEALTH AND DENTAL INSURANCE FORMS FOR RETIREES NOT YET ELIGIBLE FOR MEDICARE B
- Anthem Health Insurance Application (Rev. 2013)
- Anthem Dental Insurance Application
- Dominion Dental 707X Plan Application
- Anthem Address/Name Change
VIRGINIA RETIREMENTS SYSTEM (VRS) DOCUMENTS AND FORMS
- VRS Handbook/Publications
- VRS 2 Designation of Beneficiary
- VRS 2A Designation of Beneficiary - Continuation
- VRS 15 Request for Income Tax Withholding
- VRS 45 Request for Health Insurance Credit
- VRS 57 Authorization for Direct Deposit of Monthly Benefit
- VRS 58 Name/Address Declaration for Retirees
- VRS 78 Authorization to Deduct Insurance Premiums and Application for Health Insurance Credit
- VRS 900 Authorization to Discuss VRS Account Information
- VRS 901 VRS Durable Power of Attorney
