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Maine Public Employees Retirement System
P.O. Box 349, Augusta, ME 04332-0349
toll free: (800) 451-9800 ● local: (207) 512-3100

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Group Life Insurance Forms
     
  Forms may be downloaded by clicking the corresponding form number below. The "Request Forms" e-mail is for ordering hardcopy forms only. 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
here.  Forms indicated with "+" may be viewed and completed on the screen using a recent version of Adobe Reader®, printed, and mailed to the MainePERS. You may click on any line to complete that area or use TAB to move forward and SHIFT-TAB to move back. Forms cannot be saved or altered.
Application Application for Conversion of Group Life Insurance Coverage  
Application Application of Portability of Group Life Insurance Coverage  
CL-0893 Affidavit for Estates Not Exceeding $20,000 Request Form
GI-0881+ Cancellation/Reduction in Coverage Request Form
GI-0918 Comparing Portability and Conversion Life Insurance Options  
GI-0880+ Dependent Insurance Request Form
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.)
Request Form
GI-0874+ Request for Basic and/or Additional Insurance Coverage Requiring Evidence of Insurability Request Form
GI-0919 Thinking of Your Future - Life Insurance in Retirement  
GI-0920 Third-Party Designation  

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Information contained on this Web site is neither a legal reference nor a complete statement of the laws or MainePERS administrative rules. In any conflict between this information and Maine laws or administrative rules, the laws and administrative rules shall prevail.

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