West Virginia Consolidated Public Retirement Board

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
Change of Address
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)
Request for Disability Packet
Request for Estimate of Retirement Benefits
Retired Public Safety Officer Authorization for Insurance Premium Deduction (PSOA-2018)
- PSOA Information Sheet
Retired Public Safety Officer Insurance Carrier (ICA)

CPRB © 2018 - State of West Virginia - The materials contained herein are intended for general guidance purposes only. In the event there is a discrepancy between information contained here and the WV State Code and Rules, the language in the Code and Rules shall prevail.