Maine's Public Universities - University of Maine System

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Benefit Forms

(Click here for Staff Only Benefit Forms)

Dental Insurance

CIGNA Dental Claim Form

Domestic Partner

Domestic Partnership Certification

Flexible Spending Account

FSA Claim Form

• FSA Claim Form - Medical Only

FSA Direct Deposit Form

EBPA Additional FSA Benefits Card Request Form

Health Insurance

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

Anthem Claim Form

CIGNA Medical Claim Form

CIGNA Pharmacy Claim Form

Member Social Security Number Exception Request

Life Insurance

Beneficiary Designation Form OR MaineStreet Self-Service Quick Guide

Evidence of Insurability Form

• Evidence of Insurability (Long Form) if requested by Prudential

Life Insurance Claim Form

Medical Leave

Employee Request for FMLA (pdf)

Employee Request for Advance of Disability Leave (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 benefits enrollment , call toll-free 866-269-9635 (or 973-3373) or email benefits@maine.edu.  Be prepared to give your Employee ID number.

 

Last Updated:  February 8, 2013