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Employer Forms

Forms may be downloaded by clicking the download links below. To request hardcopy forms, please send an email request via the link in the “Request form via email” column next to the form name. For all other inquiries, please contact MainePERS directly. 

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Forms cannot be saved or altered.

Form NumberForm NameDownload form as PDFRequest form via email
PackageService Retirement Application PackageDownload PackageRequest Package
AC-1181Authorization Agreement for Preauthorized ACH Debits - MaineSTARTn/aRequest AC-1181
AC-1182Authorization Agreement for Preauthorized ACH Credits -DB and GLI Plansn/aRequest AC-1182
AC-1184Authorization Agreement for Preauthorized ACH Credits - MaineSTARTn/aRequest AC-1184
CL-0722Designation of Beneficiary Pre-Retirement Death Benefits
(Individuals completing this form might also consider completing the Change of Beneficiary Group Life Insurance form.)
Download CL-0722Request CL-0722
CL-0722AInformation Regarding Designation of Beneficiary Pre-Retirement Death BenefitsDownload CL-0722ARequest CL-0722A
EM-0003MainePERS Employer Security Administrator Authorization Download EM-0003Request EM-0003
GI-0874Request for Basic and/or Additional Insurance Coverage Requiring Evidence of InsurabilityDownload GI-0874Request GI-0874
GI-0880Dependent InsuranceDownload GI-0880Request GI-0880
GI-0881Cancellation/Reduction in CoverageDownload GI-0881Request GI-0881
GI-0912Designation of Beneficiary - Group Life Insurance
(Individuals completing this form might also consider completing the Designation of Beneficiary Pre-Retirement Death Benefits form.)
Download GI-0912Request GI-0912
GU-1016Payment or Award at Retirement Certification FormDownload GU-1016Request GU-1016
GU-1021Confidentiality Election Form - Home Contact InformationDownload GU-1021Request GU-1021
MM-0002Member/Benefit Recipient Data UpdateDownload MM-0002Request MM-0002
SSA-1945Statement Concerning Your Employment in a Job Not Covered by Social SecurityDownload SSA-1945Request SSA-1945