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 Number | Form Name | Download form as PDF | Request form via email |
|---|---|---|---|
| Package | Service Retirement Application Package | Download Package | Request Package |
| AC-1181 | Authorization Agreement for Preauthorized ACH Debits - MaineSTART | n/a | Request AC-1181 |
| AC-1182 | Authorization Agreement for Preauthorized ACH Credits -DB and GLI Plans | n/a | Request AC-1182 |
| AC-1184 | Authorization Agreement for Preauthorized ACH Credits - MaineSTART | n/a | Request AC-1184 |
| 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.) | Download CL-0722 | Request CL-0722 |
| CL-0722A | Information Regarding Designation of Beneficiary Pre-Retirement Death Benefits | Download CL-0722A | Request CL-0722A |
| EM-0003 | MainePERS Employer Security Administrator Authorization | Download EM-0003 | Request EM-0003 |
| EM-0005 | Annual Employer Self Service (ESS) Security Compliance Certification | Download EM-0005 | Request EM-0005 |
| GI-0874 | Request for Basic and/or Additional Insurance Coverage Requiring Evidence of Insurability | Download GI-0874 | Request GI-0874 |
| GI-0880 | Dependent Insurance | Download GI-0880 | Request GI-0880 |
| GI-0881 | Cancellation/Reduction in Coverage | Download GI-0881 | Request GI-0881 |
| 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.) | Download GI-0912 | Request GI-0912 |
| GU-1016 | Payment or Award at Retirement Certification Form | Download GU-1016 | Request GU-1016 |
| GU-1021 | Confidentiality Election Form - Home Contact Information | Download GU-1021 | Request GU-1021 |
| MM-0002 | Member/Benefit Recipient Data Update | Download MM-0002 | Request MM-0002 |
| SSA-1945 | Statement Concerning Your Employment in a Job Not Covered by Social Security | Download SSA-1945 | Request SSA-1945 |
