Forms

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 and non-Medicare retirees) 

• Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc.  Please note, incomplete forms will be returned.
• Employee Election to Cancel Health Insurance Form (PDF)
• Retiree Health Insurance Enrollment Form (PDF)
• Certification for Future Enrollment Form (PDF)

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Health Benefits (for Medicare retirees) 

• Retiree Health Insurance Enrollment Form (PDF)
• Certification for Future Enrollment Form (PDF)
• 2021 Application Form (PDF)
• 2020 Application Form (PDF)
• 2019 Application Form (PDF)
• Prescription Drug Claim Form (PDF)
• Pharmacy Mail Order Form (PDF)

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Dental Benefits

• Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc.  Please note, incomplete forms will be returned.
• Claim Form (PDF)

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Vision Benefits

• Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc.  Please note, incomplete forms will be returned.
• Blue View Vision Claim Form (PDF) - To file a claim for services provided out of network
• EFT Form (MS-Word) - To sign up for automatic premium payment from your bank account
• Provider Recruitment Request Form (MS-Word)

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MaineSaves 457b

(voluntary retirement savings)

• Visit our website or contact a local representative.

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Flexible Spending Accounts

• 2021 Enrollment Form (PDF)
• Change In Status Form (PDF) or Online Change In Status Form
• FSA Claim Form- Blank (PDF)

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Health Credit Premium Program

• Health Credit Appeal Form (PDF) - appeals deadline December 4, 2020

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Retired Law Enforcement and Fire Fighter Subsidy Program

(County & Municipal employees only)

• Employee Enrollment Application (PDF)
• Retiree Application to Determine Eligibility MS Word
• Employee Withdrawal Form (MS-Word)

For Employees:

• Status Change Form (MS-Word)
• Application for Retirement Subsidy (MS-Word)
• Appeal Form (MS-Word)

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Wellness Programs

 

• Living Resources Training Request Form (MS-Word) (please submit to: paige.s.lamarre@maine.gov) 
• Gym Membership Reimbursement Request Form (MS-Word)
• Gym Attendance Verification Worksheet (MS-Word)
• Wise & Well Nomination Form (PDF)

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Other

• Domestic Partner Affidavit (pdf)
• Imputed Income Notice (Word)
• Termination of Domestic Partnership (pdf)
• One Time Election of Health Insurance Form (pdf) 

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