Employer - Group Life Insurance

Employer Forms

Forms may be downloaded by clicking the corresponding form number below. The "Request Forms" e-mail is for ordering hardcopy forms only. For all other inquiries, please contact MainePERS directly.

Note: The forms below are specific to Employers use. For all other MainePERS forms, visit the Forms section.

To use these forms you will need Adobe Reader. If you don't have Reader, you can get it free by visiting www.adobe.com.


GI-0908+	Application for Coverage Group Life Insurance	Request Form
CL-0102+	Application for Membership	Request Form
CL-0102P+	Application for Membership - Participating Local District	Request Form
AC-1182	Authorization Agreement for Preauthorized ACH Credits - DB Plan	Request Form
AC-1181	Authorization Agreement for Preauthorized ACH Debits - DB Plan	Request Form
GI-0881+	Cancellation/Reduction in Coverage	Request Form
GU-1021	Confidentiality Election Form - Home Contact Information	Request Form
GI-0880+	Dependent Insurance	Request Form
GI-0912+	Designation of Beneficiary - Group Life Insurance (Individuals completing this form might also consider completing the Designation of Beneficiary Pre-Retirement Death Benefits form.)	Request Form
CL-0722+	Designation of Beneficiary Pre-Retirement Death Benefits (Individuals completing this form might also consider completing the Change of Beneficiary Group Life Insurance form.)	Request Form
CL-0722A	Information Regarding Designation of Beneficiary Pre-Retirement Death Benefits	Request Form
CL-0055	Employer Preliminary Benefit Certification Form	Request Form
MM-0002+	Member/Benefit Recipient Data Update	Request Form
AC-1176+	Monthly Payroll Summary Report for PLDs in the Consolidated Plan	Request Form
AC-0004+	Monthly Payroll Summary Report for Teacher Plan	Request Form
AC-0002	Non-Consolidated Participating Local District (PLD) Monthly Payroll Summary Report	Request Form
GI-0874	Request for Basic and/or Additional Insurance Coverage Requiring Evidence of Insurability	Request Form
MM-0001⁺	Transfer in or Personnel Status Change Form	Request Form
	Service Retirement Application Package	Request Package

+ Forms indicated with "+" may be viewed and completed on the screen using a recent version of Adobe^® Reader^®, printed, and mailed to the MainePERS. You may click on any line to complete that area or use TAB to move forward and SHIFT-TAB to move back. Forms cannot be saved or altered.