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Friday, April 18, 2014
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
5 Membership Application Defined Benefit Employer, Employee
8 Special Annual Expense Charges Procedure Defined Benefit Employer
9 MERS Statement on Modification of Standard Benefit Programs Defined Benefit Employer
11 Request for Initial Actuarial Valuation Defined Benefit Employer
DB-013A Request for Benefit Change - Permanent or Temporary Defined Benefit Employer
13b Request for Projection Study Defined Benefit Employer
15 Request for Valuation of Temporary Benefit Program (Window) Defined Benefit Employer
17 Employee Census Defined Benefit Employer
19 Uniform Resolution Defining Hours Per Month for Part-Time Employees and Service Credit Conversion Upon Promotion to Full-Time Status Defined benefit Employer
MD-069 Resolution Adopting the MERS Defined Contribution Plan Defined Contribution Employer
MD-069b Administrative Order Adopting the MERS Defined Contribution Plan Defined Contribution Employer
MD-070 MERS Defined Contribution Plan Adoption Agreement Defined Contribution Employer
MD-071 MERS Loan Addendum Defined Contribution Employer
MD-072 Defined Contribution Conversion Addendum Defined Contribution Employer
MD-060 Defined Contribution Adoption Checklist Defined Contribution Employer
51 Application for Disability Retirement Defined Benefit, Disability Employer, Employee
53 Physician's Statement Defined Benefit, Disability Employer, Employee
54 Psychiatric Medical Report Defined Benefit, Disability Employer, Employee
77 Reciprocal Retirement Act (“Act 88”) - Adopting Units Defined Benefit, Defined Contribution, Hybrid Employer, Employee
79 Resolution adopting Act 88 Defined Benefit, Defined Contribution, Hybrid Employer
82 Resolution Adopting Benefit Program PRO (Post-Retirement Option) Defined Benefit Employer
85 Customer Contact Defined Benefit, Defined Contribution Plan, Health Care Savings Program, 457 Employer
86 MERS Enforcement Procedure for Prompt Reporting and Payment Defined Benefit, Hybrid Employer
90 Restated Policy for Closed Groups Defined Benefit, Hybrid Employer
91 Amortization Policy for Closed Divisions Within Open Municipalities Defined Benefit, Defined Contribution Employer
94 Employer Resolution Establishing Uniform Transfer Provision Defined Benefit, Defined Contribution, Hybrid Employer
MD-369 Resolution Adopting MERS Hybrid Plan Hybrid Employer
MD-369b Administrative Order Adopting MERS Hybrid Hybrid Employer
MD-370 Hybrid Plan Adoption Agreement Hybrid Employer
MD-371 Hybrid Loan Addendum Hybrid Employer
MD-372 Hybrid Conversion Addendum Hybrid Employer
MD-400 457 Program Enrollment Kit 457 Employer, Employee
MD-469 457 Uniform Resolution 457 Employer
MD-470 457 Participation Agreement 457 Employer
MD-471 457 Loan Addendum 457 Employer
MD-473 457 Employer Contribution Addendum 457 Employer
MD-474 457 Eligible Automatic Contribution Arrangement (EACA) Addendum 457 Employer
2160 Proposal Process & Data Checklist Group Life & Disability Insurance Employer
None Defined Contribution Enrollment Kit Defined Contribution Employer
None Plan Document 457 Employer
None Hybrid Enrollment Kit Hybrid Employer
None Health Care Savings Program Enrollment Kit Health Care Savings Program Employer
None HCSP & RHFV Restated MERS Trust Agreement Health Care Savings Program, Retiree Health Funding Vehicle Employer
None HCSP & RHFV Plan Document Health Care Savings Program, Retiree Health Funding Vehicle Employer
MD-169 HCSP Uniform Resolution Health Care Savings Program Employer
MD-170 HCSP Participation Agreement Health Care Savings Program Employer
RH-669 RHFV Uniform Resolution Retiree Health Funding Vehicle Employer
RH-610 Retiree Health Funding Vehicle Direct Deposit Agreement Retiree Health Funding Vehicle Employer
None Life Insurance Enrollment and Change Group Life & Disability Insurance Employer
None Medical History Statement Group Life & Disability Insurance Employer
None Application for Group Insurance with 25 Employees or Over Group Life & Disability Insurance Employer
None Application for Group Insurance with Under 25 Employees Group Life & Disability Insurance Employer
None Life Insurance Benefits Claim Packet Group Life & Disability Insurance Employer
None Accelerated Benefit Claim Packet Group Life & Disability Insurance Employer
None Waiver of Premium Claim Packet Group Life & Disability Insurance Employer
None Life Insurance Portability Form Group Life & Disability Insurance Employer
None Request for Life Conversion Materials Group Life & Disability Insurance Employer
None Disability Claim Packet Group Life & Disability Insurance Employer
None Accidental Dismemberment Claim Packet Group Life & Disability Insurance Employer
DB-001a Administrative Order Adopting The Municipal Employees' Retirement System Defined Benefit Plan Defined Benefit Employer
DB-001b Resolution Adopting The Municipal Employees' Retirement System Defined Benefit Plan Defined Benefit Employer
DB-002 Defined Benefit Adoption Agreement Defined Benefit Employer
DB-092 Amortization Election Change Form Defined Benefit 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
MD-505 ISP Distribution Form ISP 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).