Virginia Mirror Company

www.va-glass.com

Health and Welfare

Pension

Additional Information

Dental Schedule

 Pension Schedule

COBRA

Health and Welfare Plan Schedule

Creditable Coverage

Disqualifying Employment Rules

Health and Welfare Forms

Pension Forms

Request new/additional insurance cards

Change of Address Form

Beneficiary Designation

Change of Beneficiary Form

Contingent Annuitant Election Form

COB Yearly Update (Participant)

Early Vested Benefit Election/Rejection Form

COB Yearly Update (Qualifying Child)

Early Survivor Benefit Election/Rejection Form

Dependent Form

Electronic Funds Transfer Form

Dependent SSN Request Form

Joint and Survivor Election Form

Disability Claim Form

Joint and Survivor Rejection Form

Disability Continuance Form

Pension Application

Enrollment Form

Post-retirement Approval Form

Injury Report

Post-retirement Employment Form

Insurance Verification Form

Retiree Coverage Insurance Inquiry

Marital/Divorce Status Form

VA-4 State Tax Withholding Form

Pre-existing Condition Form

W-4 Federal Tax Withholding Form

Qualifying Child Enrollment Form

Rx Solutions Mail Order Form

Rx Solutions Reimbursement Form

Retiree Insurance Verification Form

Student Verification Form