Notification of Death Form

We are sorry for your loss and are here to assist you during this difficult time. Reporting the death of a member, retiree, or beneficiary in a timely manner is important in order to avoid any overpayment of benefits and to begin processing benefits due to beneficiaries. Please complete the form below to report the death of a member, retiree, or beneficiary.

All fields marked with * are required. If a required field is missed it will be highlighted upon submission.

"*" indicates required fields

Step 1: Your Contact Information

Please complete all of the fields below. This is information to help us connect with you. If you do not have an email address, you may skip that field.

Name:*

First Middle Last

Address:*

Street Address Address Line 2 City State ZIP Code

Phone:

Email:

What is your relationship to the deceased?

Step 2: Deceased Person's Information

Please complete all the fields below regarding the member, retiree, or beneficiary who has passed.

Deceased Person's Name:

First Middle Last

Date of Death:

Did the deceased have a Spouse?*

Yes

If yes, please provide Name:

First Middle Last

Phone:

Email:

If Spouse is deceased, please provide Date of Death:

If there is no surviving spouse, please provide the names and contact information for any surviving children.

Additional Comments:

MainePERS may contact you if we require any additional documentation. Once the completed information and documentation is received, we will start the review process.

Name

This field is for validation purposes and should be left unchanged.