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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. 

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Forms cannot be saved or altered.

Form NumberForm NameDownload form as PDFRequest form via email
ApplicationApplication for Portability or Conversion from Group Life InsuranceDownload Applicationn/a
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-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
GI-0920Third-Party DesignationDownload GI-0920n/a