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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 - Survivor Benefits
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
CL-0888+ Consent Form Designating Authorized Representatives Request Form
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.)
Request Form
CL-0722A Information Regarding Designation of Beneficiary Pre-Retirement Death Benefits Request Form
CL-0720+ Designation of Option One Beneficiary
(NOTE: This form should be used ONLY if you are retired under option 1)
Request Form
CL-0065+ Survivor Benefits Recipient's Certification Request Form
+ 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.

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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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