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.

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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)

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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.

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Vision Benefits

• Benefits Enrollment/Change Form (PDF)
• Anthem Blue View Vison Out-of-Network Claim Form (PDF)
• Dispute Form (PDF)
  • Please utilize this form if you have a dispute regarding your premium billing.

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MaineSaves 457b

• State of Maine Joinder Deferral Agreement (PDF)

(Voluntary Retirement Savings)

• Visit our website or contact a local representative.

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Flexible Spending Accounts

• Change In Status Form (PDF) 
• ASIFlex New Hire FSA Enrollment Form (PDF)
• ASIFlex FSA Claim Form (PDF)
• ASIFlex Dependent Care Auto-Reimbursement Form (PDF)
• ASIFlex Additional Forms

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Health Credit Premium Program

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Retired Law Enforcement and Fire Fighter Subsidy Program

(County & Municipal Employees Only)

• Employee Enrollment Application (PDF)
• Employee Withdrawal Form (PDF)

For Employees:

• Status Change Form (PDF)
• Appeal Form (PDF)
• Application for Retirement Subsidy (PDF)
• Employee Election Application for the Health Insurance Subsidy Program (PDF)

For Retirees:

• Retiree Application to Determine Eligibility (PDF)
• Reimbursement Subsidy Form for Retiree Health Insurance (PDF) 

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Wellness Programs

• Living Resources Training Request Form 
• Gym Membership Reimbursement Request Form (PDF)
• Gym Attendance Verification Worksheet (PDF)
• Wise & Well Nomination Form (PDF)

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Other

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

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