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Wednesday, July 27, 2016
MERS Forms

Employer Forms

Whether you're enrolling a new employee, ready to sign adoption or participation agreements, updating contact information or much more, you'll find all our Employer Forms here. Click the links on the left to view the forms specific to your MERS program. To view a list of all our MERS forms, click here.

Form # Name Product Audience Online Info
DB-002c Addendum Defining Part-Time to Full-Time Service Credit Conversion Defined benefit Employer more information

Addendum Defining Part-Time to Full-Time Service Credit Conversion

Form #: DB-002c

Product: Defined benefit
Audience: Employer

5 Defined Benefit Membership Application Defined Benefit Employer, Employee more information

Defined Benefit Membership Application

Form #: 5

Product: Defined Benefit
Audience: Employer, Employee

DB-013A Request for Benefit Change - Permanent or Temporary Defined Benefit Employer more information

Request for Benefit Change - Permanent or Temporary

Form #: DB-013A

Product: Defined Benefit
Audience: Employer

DB-013b Request for Projection Study Defined Benefit, Defined Contribution, Hybrid Employer more information

Request for Projection Study

Form #: DB-013b

Product: Defined Benefit, Defined Contribution, Hybrid
Audience: Employer

17 Employee Census Defined Benefit Employer more information

Employee Census

Form #: 17

Product: Defined Benefit
Audience: Employer

MD-069 Resolution Adopting the MERS Defined Contribution Plan Defined Contribution Employer more information

Resolution Adopting the MERS Defined Contribution Plan

Form #: MD-069

Product: Defined Contribution
Audience: Employer

MD-069b Administrative Order Adopting the MERS Defined Contribution Plan Defined Contribution Employer more information

Administrative Order Adopting the MERS Defined Contribution Plan

Form #: MD-069b

Product: Defined Contribution
Audience: Employer

MD-070 MERS Defined Contribution Plan Adoption Agreement Defined Contribution Employer more information

MERS Defined Contribution Plan Adoption Agreement

Form #: MD-070

Product: Defined Contribution
Audience: Employer

MD-071 MERS Loan Addendum Defined Contribution Employer more information

MERS Loan Addendum

Form #: MD-071

Product: Defined Contribution
Audience: Employer

MD-072 Defined Contribution Conversion Addendum Defined Contribution Employer more information

Defined Contribution Conversion Addendum

Form #: MD-072

Product: Defined Contribution
Audience: Employer

51 Application for Disability Retirement Defined Benefit, Disability Employer, Employee more information

Application for Disability Retirement

Form #: 51

Product: Defined Benefit, Disability
Audience: Employer, Employee

F-53 Physician's Statement of Disability Defined Benefit, Disability Employer, Employee more information

Physician's Statement of Disability

Form #: F-53

Product: Defined Benefit, Disability
Audience: Employer, Employee

54 Psychiatric Medical Report Defined Benefit, Disability Employer, Employee more information

Psychiatric Medical Report

Form #: 54

Product: Defined Benefit, Disability
Audience: Employer, Employee

77 Reciprocal Retirement Act (“Act 88”) - Adopting Units Defined Benefit, Defined Contribution, Hybrid Employer, Employee more information

Reciprocal Retirement Act (“Act 88”) - Adopting Units

Form #: 77

Product: Defined Benefit, Defined Contribution, Hybrid
Audience: Employer, Employee

79 Resolution adopting Act 88 Defined Benefit, Defined Contribution, Hybrid Employer more information

Resolution adopting Act 88

Form #: 79

Product: Defined Benefit, Defined Contribution, Hybrid
Audience: Employer

85 Customer Contact Defined Benefit, Defined Contribution Plan, Health Care Savings Program, 457 Employer more information

Customer Contact

Form #: 85

Product: Defined Benefit, Defined Contribution Plan, Health Care Savings Program, 457
Audience: Employer

86 MERS Enforcement Procedure for Prompt Reporting and Payment Defined Benefit, Hybrid Employer more information

MERS Enforcement Procedure for Prompt Reporting and Payment

Form #: 86

Product: Defined Benefit, Hybrid
Audience: Employer

90 Restated Policy for Closed Groups Defined Benefit, Hybrid Employer more information

Restated Policy for Closed Groups

Form #: 90

Product: Defined Benefit, Hybrid
Audience: Employer

91 Amortization Policy for Closed Divisions Within Open Municipalities Defined Benefit, Defined Contribution Employer more information

Amortization Policy for Closed Divisions Within Open Municipalities

Form #: 91

Product: Defined Benefit, Defined Contribution
Audience: Employer

94 Employer Resolution Establishing Uniform Transfer Provision Defined Benefit, Defined Contribution, Hybrid Employer more information

Employer Resolution Establishing Uniform Transfer Provision

Form #: 94

Product: Defined Benefit, Defined Contribution, Hybrid
Audience: Employer

MD-000 Defined Contribution Enrollment Kit Defined Contribution Employer, Employee more information

Defined Contribution Enrollment Kit

Form #: MD-000

Product: Defined Contribution
Audience: Employer, Employee

MD-010 Defined Contribution Loan Application Defined Contribution Employee more information

Defined Contribution Loan Application

Form #: MD-010

Product: Defined Contribution
Audience: Employee

MD-369 Resolution Adopting MERS Hybrid Plan Hybrid Employer more information

Resolution Adopting MERS Hybrid Plan

Form #: MD-369

Product: Hybrid
Audience: Employer

MD-369b Administrative Order Adopting MERS Hybrid Hybrid Employer more information

Administrative Order Adopting MERS Hybrid

Form #: MD-369b

Product: Hybrid
Audience: Employer

MD-370 Hybrid Plan Adoption Agreement Hybrid Employer more information

Hybrid Plan Adoption Agreement

Form #: MD-370

Product: Hybrid
Audience: Employer

MD-371 Hybrid Loan Addendum Hybrid Employer more information

Hybrid Loan Addendum

Form #: MD-371

Product: Hybrid
Audience: Employer

MD-372 Hybrid Conversion Addendum Hybrid Employer more information

Hybrid Conversion Addendum

Form #: MD-372

Product: Hybrid
Audience: Employer

MD-400 457 Program Enrollment Kit 457 Employer, Employee more information

457 Program Enrollment Kit

Form #: MD-400

Product: 457
Audience: Employer, Employee

MD-469 457 Uniform Resolution 457 Employer more information

457 Uniform Resolution

Form #: MD-469

Product: 457
Audience: Employer

MD-470 457 Participation Agreement 457 Employer more information

457 Participation Agreement

Form #: MD-470

Product: 457
Audience: Employer

MD-471 457 Loan Addendum 457 Employer more information

457 Loan Addendum

Form #: MD-471

Product: 457
Audience: Employer

MD-473 457 Employer Contribution Addendum 457 Employer more information

457 Employer Contribution Addendum

Form #: MD-473

Product: 457
Audience: Employer

MD-474 457 Eligible Automatic Contribution Arrangement (EACA) Addendum 457 Employer more information

457 Eligible Automatic Contribution Arrangement (EACA) Addendum

Form #: MD-474

Product: 457
Audience: Employer

2160 Proposal Process & Data Checklist Group Life & Disability Insurance Employer more information

Proposal Process & Data Checklist

Form #: 2160

Product: Group Life & Disability Insurance
Audience: Employer

None Plan Document 457 Employer more information

Plan Document

Form #: None

Product: 457
Audience: Employer

MD-300 Hybrid Enrollment Kit Hybrid Employer, Employee more information

Hybrid Enrollment Kit

Form #: MD-300

Product: Hybrid
Audience: Employer, Employee

MD-100 Health Care Savings Program Enrollment Kit Health Care Savings Program Employer, Employee more information

Health Care Savings Program Enrollment Kit

Form #: MD-100

Product: Health Care Savings Program
Audience: Employer, Employee

None HCSP & RHFV Restated MERS Trust Agreement Health Care Savings Program, Retiree Health Funding Vehicle Employer more information

HCSP & RHFV Restated MERS Trust Agreement

Form #: None

Product: Health Care Savings Program, Retiree Health Funding Vehicle
Audience: Employer

None HCSP & RHFV Plan Document Health Care Savings Program, Retiree Health Funding Vehicle Employer more information

HCSP & RHFV Plan Document

Form #: None

Product: Health Care Savings Program, Retiree Health Funding Vehicle
Audience: Employer

MD-169 HCSP Uniform Resolution Health Care Savings Program Employer more information

HCSP Uniform Resolution

Form #: MD-169

Product: Health Care Savings Program
Audience: Employer

MD-170 HCSP Participation Agreement Health Care Savings Program Employer more information

HCSP Participation Agreement

Form #: MD-170

Product: Health Care Savings Program
Audience: Employer

RH-605 Retiree Health Funding Vehicle Distribution Request Retiree Health Funding Vehicle Employer more information

Retiree Health Funding Vehicle Distribution Request

Form #: RH-605

Product: Retiree Health Funding Vehicle
Audience: Employer

RH-669 RHFV Uniform Resolution Retiree Health Funding Vehicle Employer more information

RHFV Uniform Resolution

Form #: RH-669

Product: Retiree Health Funding Vehicle
Audience: Employer

None Life Insurance Enrollment and Change Group Life & Disability Insurance Employer more information

Life Insurance Enrollment and Change

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Medical History Statement Group Life & Disability Insurance Employer more information

Medical History Statement

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Application for Group Insurance with 25 Employees or Over Group Life & Disability Insurance Employer more information

Application for Group Insurance with 25 Employees or Over

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Application for Group Insurance with Under 25 Employees Group Life & Disability Insurance Employer more information

Application for Group Insurance with Under 25 Employees

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Life Insurance Benefits Claim Packet Group Life & Disability Insurance Employer more information

Life Insurance Benefits Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Accelerated Benefit Claim Packet Group Life & Disability Insurance Employer more information

Accelerated Benefit Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Waiver of Premium Claim Packet Group Life & Disability Insurance Employer more information

Waiver of Premium Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Life Insurance Portability Form Group Life & Disability Insurance Employer more information

Life Insurance Portability Form

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Request for Life Conversion Materials Group Life & Disability Insurance Employer more information

Request for Life Conversion Materials

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Disability Claim Packet Group Life & Disability Insurance Employer more information

Disability Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

None Accidental Dismemberment Claim Packet Group Life & Disability Insurance Employer more information

Accidental Dismemberment Claim Packet

Form #: None

Product: Group Life & Disability Insurance
Audience: Employer

DB-001a Administrative Order Adopting The Municipal Employees' Retirement System Defined Benefit Plan Defined Benefit Employer more information

Administrative Order Adopting The Municipal Employees' Retirement System Defined Benefit Plan

Form #: DB-001a

Product: Defined Benefit
Audience: Employer

DB-001b Resolution Adopting The Municipal Employees' Retirement System Defined Benefit Plan Defined Benefit Employer more information

Resolution Adopting The Municipal Employees' Retirement System Defined Benefit Plan

Form #: DB-001b

Product: Defined Benefit
Audience: Employer

DB-002 Defined Benefit Adoption Agreement Defined Benefit Employer more information

Defined Benefit Adoption Agreement

Form #: DB-002

Product: Defined Benefit
Audience: Employer

FN-003 ACH Debit Request - Automated Transfer Authorization Defined Contribution Plan, Hybrid, Health Care Savings Program, 457, Retiree Health Funding Vehicle, Investment Services Program Employer more information

ACH Debit Request - Automated Transfer Authorization

Form #: FN-003
Description:

Employer Form: Banking information for employer to set up ACH transfer authorization for MERS DC, 457, HCSP, RHFV, and ISP.


Product: Defined Contribution Plan, Hybrid, Health Care Savings Program, 457, Retiree Health Funding Vehicle, Investment Services Program
Audience: Employer

MD-505 ISP Distribution Form ISP Employer more information

ISP Distribution Form

Form #: MD-505

Product: ISP
Audience: Employer

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Disclaimer
The information contained in this Web site is being made available as a public service. The information is not intended to constitute legal or investment advice, or to replace official versions of that information. Benefit Estimates or Service Credit Purchase estimates requested through this Web site are not official descriptions of any benefits, and do not represent a promise by MERS to provide any benefit(s) to any person(s). No one can detrimentally rely upon the information provided in, or requested through this Web site. MERS reserves the right to correct any errors, and presents this information without warranties, express or implied, regarding the information?s accuracy, timeliness or completeness. If you believe the information is inaccurate, out-of-date, or incomplete, or if you have problems accessing or reading the information, please call MERS at 800.767.MERS (6377).