Group Life Insurance Forms

Forms may be downloaded by clicking the download links below. To request a hardcopy form, 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.

To use these forms you will need Adobe Reader®.  Information on completing forms with Reader®.  Forms using Adobe Reader can be printed, but cannot be saved electronically.

Digital Signature Forms through DocuSign: A number of forms are available for completion online with your digital signature and these forms are identified in the “Digital Signature Forms” column next to the form name. The form is completed, signed, and submitted electronically. You will have an option to save an electronic copy of any form you opt to fill out electronically and sign digitally.

Once you select the document, step-by-step directions are available within the DocuSign application.

Click here for more information on digital signatures

Digital Signature:

A digital signature means a computer-created electronic signature that is:

  • unique to the person using it;
  • intended by the person using it to have the same force and effect as the use of a manual signature;
  • capable of verification;
  • under the sole control of the person using it; and
  • linked to data in such a manner that it is invalidated if changes are made to the data.

Digital signatures require creation by specialized software platforms.

Form NumberForm NameDownload form as PDFRequest form via emailDigital Signature Forms
CL-0893Affidavit for Estates Not Exceeding $40,000Download CL-0893Request CL-0893
GI-0874Request for Basic and/or Additional Insurance Coverage Requiring Evidence of InsurabilityDownload GI-0874Request GI-0874Download DocuSign Form 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 Pension Beneficiary Designation for Pre-Retirement Death Benefits form.)
Download GI-0912Request GI-0912Download DocuSign Form GI-0912
GI-0920Third-Party DesignationDownload GI-0920n/a