THE WEST VIRGINIA STATE POLICE DEATH, DISABILITY AND RETIREMENT FUND (PLAN A) Forms

• Application for Refund of Accumulated Contributions
• Application for Scholarship
• Authorization to Release Information
• Benefit Estimate Request
• Change of Name
• Combined Medical Power of Attorney and Living Will (print on legal size paper)
• Confidential Records Order
• Disability Recertification Policy
• Employee of the Month Nomination Form
• Less Than Honorable Service
• Living Will (print on legal size paper)
• Medical Power of Attorney (print on legal size paper)
• Qualified Domestic Relations Order (QDRO)
• Retired Public Safety Officer Authorization for Insurance Premium Deduction (PSOA-2022)
• Retired Public Safety Officer Insurance Carrier (ICA)