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Office of Human Resources: Employee Benefits Links to forms
Most forms are in fillable pdf. (What is pdf?) Search for a specific form by keyword in the Find window: Control-F
Health Insurance Enrollment Form for Active Employees
StateActiveEnrollForm
COVA Care Plan
Anthem Claim Form http://www.anthem.com/shared/noapplication/f5/s1/t0/pw_m008894.pdf
Medco Prescription Drug Reimbursement Form
Medco Prescriptions By Mail Order Form
Medco FAX Prescriptions Form
COVA Connect Plan
VRS Beneficiary Designation Form http://www.varetire.org/Pdf/vrs-2fill.pdf
Application to Purchase Prior Service http://www.varetire.org/Pdf/vrs-26fill.pdf
Agreement for Salary Reduction to Purchase Service Credit http://www.varetire.org/Pdf/vrs-26efill.pdf
Authorization for After-Tax Payroll Deduction to Purchase Service Credit http://www.varetire.org/Pdf/vrs-26cfill.pdf
Request for Review of Membership Records http://www.varetire.org/Pdf/vrs-70fill.pdf
Request for Estimate of Service Retirement Benefits http://www.varetire.org/Pdf/vrs-60fill.pdf
Election to Participate - ORP for Higher Education http://www.varetire.org/Pdf/vrs-65fill.pdf
Termination Certification Form - ORP for Higher Education http://www.varetire.org/Pdf/vrs-65dfill.pdf
ORP Health Insurance Credit Employer Certification of Service http://www.varetire.org/Pdf/vrs-75fill.pdf
Optional Group Life Insurance Enrollment Form https://web1.lifebenefits.com/lbe/grppdforms/VRS009643/52833.pdf
Evidence of Insurability Form https://web1.lifebenefits.com/lbe/grppdforms/VRS009643/52749.pdf
Change Form for Optional Group Life Insurance Plan https://web1.lifebenefits.com/lbe/grppdforms/VRS009643/53411.pdf
Forms
Salary Reduction Agreement - 403(b) Plan
Cash Match Agreement
Administrative and Teaching Faculty Leave Request Form 1-2010
Request for Family and Medical Leave
