Some of the files below are PDF or MS Word files which require the free Adobe Reader and Word Viewer.
On this page:
- Health Benefits (for active employees & non-Medicare retirees)
- Health Benefits (for Medicare retirees)
- Dental Benefits
- Vision Benefits
- MaineSaves 457b
- Flexible Spending Accounts
- Health Credit Premium Program
- Retired Law Enforcement and Fire Fighter Subsidy Program
- Wellness Programs
- Other
Health Benefits (For Active Employees & Non-Medicare Retirees)
- Benefits Enrollment/Change Form (PDF)
- Employee Election to Cancel Health Insurance Form (PDF)
- Retiree Health Insurance Enrollment Form (PDF)
- Certification for Future Enrollment Form (PDF)
- State of Maine New Hire Letter
- Dispute Form (PDF)
- Please utilize this form if you have a dispute regarding your premium billing.
Health Benefits (For Medicare Retirees)
- Retiree Health Insurance Enrollment Form (PDF)
- Certification for Future Enrollment Form (PDF)
- 2022 Application Form (PDF)
- Prescription Drug Claim Form (PDF)
- Pharmacy Mail Order Form (PDF)
Dental Benefits
- Benefits Enrollment/Change Form (PDF)
- Claim Form (PDF)
- Dispute Form (PDF)
- Please utilize this form if you have a dispute regarding your premium billing.
Vision Benefits
- Benefits Enrollment/Change Form (PDF)
- Claim Reimbursement Form
- Dispute Form (PDF)
- Please utilize this form if you have a dispute regarding your premium billing.
MaineSaves 457b
(Voluntary Retirement Savings)
- Visit our website or contact a local representative.
Flexible Spending Accounts
- Change In Status Form (PDF) or Online Change In Status Form
- ASIFlex New Hire FSA Enrollment Form (PDF)
- ASIFlex FSA Claim Form (PDF)
- ASIFlex Dependent Care Auto-Reimbursement Form (PDF)
- ASIFlex Additional Forms
Health Credit Premium Program
- Health Credit Appeal Form (PDF) - appeals deadline August 7, 2023
Retired Law Enforcement and Fire Fighter Subsidy Program
(County & Municipal Employees Only)
For Employees:
- Status Change Form (PDF)
- Appeal Form (PDF)
- Application for Retirement Subsidy (PDF)
- Employee Election Application for the Health Insurance Subsidy Program (PDF)
- Retiree Application to Determine Eligibility (PDF)
- Reimbursement Subsidy Form for Retiree Health Insurance (PDF)
Wellness Programs
- Living Resources Training Request Form
- Gym Membership Reimbursement Request Form (PDF)
- Gym Attendance Verification Worksheet (PDF)
- Wise & Well Nomination Form (PDF)