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Survivor Benefit 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 NumberForm NameDownload form as PDFRequest form via email
CL-0065Survivor Benefits Recipient's CertificationDownload CL-0065Request CL-0065
CL-0720Designation of Option One Beneficiary
(NOTE: This form should be used ONLY if you are retired under option 1)
Download CL-0720Request CL-0720
CL-0722Designation of Beneficiary Pre-Retirement Death Benefits
(Individuals completing this form might also consider completing the Designation 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
CL-0888Consent Form Designating Authorized RepresentativesDownload CL-0888Request CL-0888
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