Maine's Public Universities - University of Maine System

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Benefit Forms

(Staff Only Benefit Forms)

Dental Insurance

CIGNA Dental Claim Form

Domestic Partner

Affidavit of Domestic Partnership

Flexible Spending Account

FSA Claim Form

FSA Direct Depost Form

EBPA Additional FSA Benefits Card Request Form

Health Insurance

Authorization for the Use and/or Disclosure of Protected Health Information

Anthem Claim Form

Life Insurance

Beneficiary Designation Form

Evidence of Insurability Form

Medical Leave

Employee Request for FMLA (pdf)

Certification of Ability to Return to Work (pdf)

Certification of Qualifying Exigency for Military Family Leave

Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave

Certification of Health Care Provider for Family Member’s Serious Health Condition

Certification of Health Care Provider for Employee’s Serious Health Condition

Retiree Forms

SmartValue Application

Retirement Savings

Salary Reduction Agreement for Salaried Employees

Salary Reduction Agreement for Hourly-Paid Employees

Incentive Retirement Plan Application

Partial/Phased Retirement Plan Application

Classified Retirement Plan Application for Benefits

Classified Retirement Plan Designation of Beneficiary

Tuition Waiver

Request Employee Tuition Waiver 

Request Dependent Tuition Waiver

Vision

CIGNA Vision Claim Form

Workers Compensation

Incident Report Form

 

 

Contact Benefits

If you have a question about your benefits coverage, benefit deduction amounts or any other benefit related question, contact your Campus Benefits Office.  Be prepared to give your Employee ID number.

 

Last Updated:  November 12, 2009