Group Life Insurance 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.
To use these forms you will need Adobe Reader®. If you don’t have Reader, you can get it free by clicking the Adobe link above. For information on completing forms with Reader® click here.
Forms cannot be saved or altered.
|Form Number||Form Name||Download form as PDF||Request form via email|
|Application||Application for Portability or Conversion from Group Life Insurance||Download Application||n/a|
|CL-0893||Affidavit for Estates Not Exceeding $40,000||Download CL-0893||Request CL-0893|
|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|
|GI-0920||Third-Party Designation||Download GI-0920||n/a|