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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
http://www.dhrm.virginia.gov/statefrm/health/ActiveEnroll08.pdf
Anthem Claim Form http://www.anthem.com/shared/noapplication/f5/s1/t0/pw_m008894.pdf
Prescription Drug Reimbursement Form
Medco Prescriptions By Mail Order Form
Medco FAX Prescriptions Form
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
457 Plan Enrollment Form http://www.fascore.com/PDF/vadcp/457_401a_combo_application.pdf
457 Plan Beneficiary Form http://www.fascore.com/PDF/vadcp/457_401a_combo_beneficiary.pdf
Payroll Authorization Form (to increase, decrease, suspend contributions) http://www.fascore.com/PDF/vadcp/VAPayrollAuthForm.pdf
Faculty Leave Reporting Form https://insidetcc.tcc.edu/hr/documents/HR-16AAdministrativeandTeachingFacultyLeaveRequestForm1-07.pdf
Classified Staff Timesheet/Leave Slip (Choose file by date on InsideTCC) https://insidetcc.tcc.edu/hr/pdfs/2006Timesheets.htm
Request for Family and Medical Leave
Family and Medical Leave Healthcare Provider Certification http://www.dol.gov/esa/regs/compliance/whd/fmla/wh380.pdf
