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