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