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-0908S	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
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 Data Update Form	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.