Sunday, February 19, 2017

MERS Forms

Legend:

= Available on myMERS. Forms with a star may be completed Online by logging into your myMERS account. Click here to log in.
 
Abbreviations
DB = Defined Benefit, DC = Defined Contribution, HCSP = Health Care Savings Program, RHFV = Retiree Health Funding Vehicle, ISP = Investment Services Program, Premier Adv = Premier Advantage, Annuity = Stable Income Annuity, GL&D = Group Life & Disability Insurance.
Form # Product Name Audience myMers Info
F-29c DB, Hybrid Working in Retirement Certification Participant False more information

Working in Retirement Certification

Form #: F-29c

Product: DB, Hybrid
Audience: Participant

F-31b DB, DC, Hybrid Withholding for Pension or Annuity Payments Participant False more information

Withholding for Pension or Annuity Payments

Form #: F-31b

Product: DB, DC, Hybrid
Audience: Participant

None GL&D Waiver of Premium Claim Packet Employer False more information

Waiver of Premium Claim Packet

Form #: None

Product: GL&D
Audience: Employer

F-27 DB, DC, Hybrid Verify Other Governmental Service Participant False more information

Verify Other Governmental Service

Form #: F-27

Product: DB, DC, Hybrid
Audience: Participant

MD-169 HCSP Uniform Resolution Employer False more information

Uniform Resolution

Form #: MD-169

Product: HCSP
Audience: Employer

RH-669 RHFV Uniform Resolution Employer False more information

Uniform Resolution

Form #: RH-669

Product: RHFV
Audience: Employer

MD-469 457 Uniform Resolution Employer False more information

Uniform Resolution

Form #: MD-469
Description:

test def.


Product: 457
Audience: Employer

MD-412 457 Unforeseeable Emergency Withdrawals Participant False more information

Unforeseeable Emergency Withdrawals

Form #: MD-412

Product: 457
Audience: Participant

F-10 DB Transfer Of Contributions (excluding Hybrid) Participant False more information

Transfer Of Contributions (excluding Hybrid)

Form #: F-10

Product: DB
Audience: Participant

F-32 DB, Hybrid Survivor Beneficiary Application Participant False more information

Survivor Beneficiary Application

Form #: F-32

Product: DB, Hybrid
Audience: Participant

F-37 DB Stop Payment Participant False more information

Stop Payment

Form #: F-37

Product: DB
Audience: Participant

6146 Annuity Statement of Beneficiary Claim to Benefits Participant False more information

Statement of Beneficiary Claim to Benefits

Form #: 6146

Product: Annuity
Audience: Participant

F-35B DB Standard Transfer Member Certification for Same Employer Participant False more information

Standard Transfer Member Certification for Same Employer

Form #: F-35B

Product: DB
Audience: Participant

MD-406 457 Spousal Beneficiary Claim Participant False more information

Spousal Beneficiary Claim

Form #: MD-406

Product: 457
Audience: Participant

MD-006 DC Spousal Beneficiary Claim Participant False more information

Spousal Beneficiary Claim

Form #: MD-006

Product: DC
Audience: Participant

DB-004 Defined Benefit Service Credit Purchase Opt-Out Form Employer False more information

Service Credit Purchase Opt-Out Form

Form #: DB-004

Product: Defined Benefit
Audience: Employer

None HCSP, RHFV Restated MERS Trust Agreement Employer False more information

Restated MERS Trust Agreement

Form #: None

Product: HCSP, RHFV
Audience: Employer

DB-001b DB Resolution Adopting The MERS Defined Benefit Plan Employer False more information

Resolution Adopting The MERS Defined Benefit Plan

Form #: DB-001b

Product: DB
Audience: Employer

MD-409 457 Required Minimum Distribution Participant False more information

Required Minimum Distribution

Form #: MD-409

Product: 457
Audience: Participant

MD-009 DC Required Minimum Distribution Participant False more information

Required Minimum Distribution

Form #: MD-009

Product: DC
Audience: Participant

None GL&D Request for Life Conversion Materials Employer False more information

Request for Life Conversion Materials

Form #: None

Product: GL&D
Audience: Employer

6614 Annuity Request for Contract Application Amendment Participant False more information

Request for Contract Application Amendment

Form #: 6614

Product: Annuity
Audience: Participant

12428 Annuity Request for Change to Annuity Policy Participant False more information

Request for Change to Annuity Policy

Form #: 12428

Product: Annuity
Audience: Participant

11436 Annuity Request for Change of EFT Annuity Payout Participant False more information

Request for Change of EFT Annuity Payout

Form #: 11436

Product: Annuity
Audience: Participant

2527 Annuity Request for Absolute Assignment / Successor Owner Endorsement Participant False more information

Request for Absolute Assignment / Successor Owner Endorsement

Form #: 2527

Product: Annuity
Audience: Participant

F-26 DB Refund Application for Deceased Member's Contributions Participant False more information

Refund Application for Deceased Member's Contributions

Form #: F-26

Product: DB
Audience: Participant

F-24 DB Refund Application Participant False more information

Refund Application

Form #: F-24

Product: DB
Audience: Participant

F-79 DB, DC, Hybrid Reciprocal Units (Act 88) - Resolution Employer False more information

Reciprocal Units (Act 88) - Resolution

Form #: F-79

Product: DB, DC, Hybrid
Audience: Employer

13018 Annuity Qualified Joint and Survivor Annuity Notice / Spousal Consent Participant False more information

Qualified Joint and Survivor Annuity Notice / Spousal Consent

Form #: 13018

Product: Annuity
Audience: Participant

F-38 DB Qualified Fund Rollover to MERS Participant False more information

Qualified Fund Rollover to MERS

Form #: F-38

Product: DB
Audience: Participant

F-54 DB Psychiatric Medical Report Employer, Participant False more information

Psychiatric Medical Report

Form #: F-54

Product: DB
Audience: Employer, Participant

2160 GL&D Proposal Process & Data Checklist Employer False more information

Proposal Process & Data Checklist

Form #: 2160

Product: GL&D
Audience: Employer

DB-013b DB, DC, Hybrid Projection Study Employer False more information

Projection Study

Form #: DB-013b

Product: DB, DC, Hybrid
Audience: Employer

F-53 DB Physician's Statement of Disability Employer, Participant False more information

Physician's Statement of Disability

Form #: F-53

Product: DB
Audience: Employer, Participant

MD-001 DB, DC, Hybrid, HCSP, 457 Personal Information Participant False more information

Personal Information

Form #: MD-001

Product: DB, DC, Hybrid, HCSP, 457
Audience: Participant

F-31 DB, Hybrid Pension Federal Income Tax Participant, Retiree False more information

Pension Federal Income Tax

Form #: F-31

Product: DB, Hybrid
Audience: Participant, Retiree

DB-002c DB Part-Time to Full-Time Service Credit Conversion Employer False more information

Part-Time to Full-Time Service Credit Conversion

Form #: DB-002c

Product: DB
Audience: Employer

MD-170 HCSP Participation Agreement Employer False more information

Participation Agreement

Form #: MD-170

Product: HCSP
Audience: Employer

MD-470 457 Participation Agreement Employer False more information

Participation Agreement

Form #: MD-470

Product: 457
Audience: Employer

F-41 DB Option IV Beneficiary Participant False more information

Option IV Beneficiary

Form #: F-41

Product: DB
Audience: Participant

MD-415 457 Opt Out Refund Participant False more information

Opt Out Refund

Form #: MD-415

Product: 457
Audience: Participant

MD-407 457 Non-Spousal Beneficiary Claim Participant False more information

Non-Spousal Beneficiary Claim

Form #: MD-407

Product: 457
Audience: Participant

MD-007 DC Non-Spousal Beneficiary Claim Participant False more information

Non-Spousal Beneficiary Claim

Form #: MD-007

Product: DC
Audience: Participant

F-72 DB Model EDRO Participant False more information

Model EDRO

Form #: F-72

Product: DB
Audience: Participant

F-71 DB Model DRO Participant False more information

Model DRO

Form #: F-71

Product: DB
Audience: Participant

F-78 HCSP Model DRO Participant False more information

Model DRO

Form #: F-78

Product: HCSP
Audience: Participant

F-75 DC Model DRO Participant False more information

Model DRO

Form #: F-75

Product: DC
Audience: Participant

F-73 457 Model DRO Participant False more information

Model DRO

Form #: F-73

Product: 457
Audience: Participant

MD-016 DC MERS-to-MERS Service Verification Participant False more information

MERS-to-MERS Service Verification

Form #: MD-016

Product: DC
Audience: Participant

MD-071 DC MERS Loan Addendum Employer False more information

MERS Loan Addendum

Form #: MD-071

Product: DC
Audience: Employer

F-05 DB Membership Application Employer, Participant False more information

Membership Application

Form #: F-05
Description:

test summary


Product: DB
Audience: Employer, Participant

None GL&D Medical History Statement Employer False more information

Medical History Statement

Form #: None

Product: GL&D
Audience: Employer

MD-410 457 Loan Application Participant False more information

Loan Application

Form #: MD-410

Product: 457
Audience: Participant

MD-010 DC Loan Application Participant False more information

Loan Application

Form #: MD-010

Product: DC
Audience: Participant

MD-371 Hybrid Loan Addendum Employer False more information

Loan Addendum

Form #: MD-371

Product: Hybrid
Audience: Employer

MD-471 457 Loan Addendum Employer False more information

Loan Addendum

Form #: MD-471

Product: 457
Audience: Employer

F-52 DB Limitation on Disability Benefits – Affidavit Participant False more information

Limitation on Disability Benefits – Affidavit

Form #: F-52

Product: DB
Audience: Participant

None GL&D Life Insurance Portability Employer False more information

Life Insurance Portability

Form #: None

Product: GL&D
Audience: Employer

None GL&D Life Insurance Enrollment / Change Employer False more information

Life Insurance Enrollment / Change

Form #: None

Product: GL&D
Audience: Employer

None GL&D Life Insurance Benefits Claim Packet Employer False more information

Life Insurance Benefits Claim Packet

Form #: None

Product: GL&D
Audience: Employer

MD-402 457 Investment Change Participant True more information

Investment Change

Form #: MD-402

Product: 457
Audience: Participant

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

MD-002 DC Investment Change Participant True more information

Investment Change

Form #: MD-002

Product: DC
Audience: Participant

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

MD-102 HCSP Investment Change Participant True more information

Investment Change

Form #: MD-102

Product: HCSP
Audience: Participant

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

MD-302 Hybrid Investment Change Participant True more information

Investment Change

Form #: MD-302

Product: Hybrid
Audience: Participant

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

MD-008 DC In-Service Withdrawal Request Participant False more information

In-Service Withdrawal Request

Form #: MD-008

Product: DC
Audience: Participant

MD-408 457 In-Service Withdrawal Participant False more information

In-Service Withdrawal

Form #: MD-408

Product: 457
Audience: Participant

MD-404 457 Incoming Transfer Participant False more information

Incoming Transfer

Form #: MD-404

Product: 457
Audience: Participant

MD-004 DC Incoming Rollover Participant False more information

Incoming Rollover

Form #: MD-004

Product: DC
Audience: Participant

MD-304 Hybrid Incoming Direct Rollover Participant False more information

Incoming Direct Rollover

Form #: MD-304

Product: Hybrid
Audience: Participant

F-36 DB, Hybrid Funds Transfer – Direct Deposit Authorization Participant False more information

Funds Transfer – Direct Deposit Authorization

Form #: F-36

Product: DB, Hybrid
Audience: Participant

MD-100 HCSP Enrollment Kit Employer, Participant False more information

Enrollment Kit

Form #: MD-100

Product: HCSP
Audience: Employer, Participant

MD-300 Hybrid Enrollment Kit Employer, Participant False more information

Enrollment Kit

Form #: MD-300

Product: Hybrid
Audience: Employer, Participant

MD-000 DC Enrollment Kit Employer, Participant False more information

Enrollment Kit

Form #: MD-000

Product: DC
Audience: Employer, Participant

MD-400 457 Enrollment Kit Employer, Participant False more information

Enrollment Kit

Form #: MD-400

Product: 457
Audience: Employer, Participant

F-94 DB, DC, Hybrid Employer Resolution Establishing Uniform Transfer Provision Employer False more information

Employer Resolution Establishing Uniform Transfer Provision

Form #: F-94

Product: DB, DC, Hybrid
Audience: Employer

MD-473 457 Employer Contribution Addendum Employer False more information

Employer Contribution Addendum

Form #: MD-473

Product: 457
Audience: Employer

F-17 DB Employee Census Employer False more information

Employee Census

Form #: F-17

Product: DB
Audience: Employer

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

Eligible Automatic Contribution Arrangement (EACA) Addendum

Form #: MD-474

Product: 457
Audience: Employer

F-42 DB DROP+ and Election Participant False more information

DROP+ and Election

Form #: F-42

Product: DB
Audience: Participant

MD-405 457 Distribution/Direct Rollover Participant True more information

Distribution/Direct Rollover

Form #: MD-405

Product: 457
Audience: Participant

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

MD-005 DC Distribution / Direct Rollover Participant True more information

Distribution / Direct Rollover

Form #: MD-005

Product: DC
Audience: Participant

myMERS: Yes, this form can be completed via an online process by logging into your myMERS account. Click to log in.

MD-505 ISP Distribution Employer False more information

Distribution

Form #: MD-505

Product: ISP
Audience: Employer

12999 Annuity Disclosure Participant False more information

Disclosure

Form #: 12999

Product: Annuity
Audience: Participant

None GL&D Disability Claim Packet Employer False more information

Disability Claim Packet

Form #: None

Product: GL&D
Audience: Employer

DB-007 Defined Benefit Defined Benefit Plan Surplus Division Adoption Addendum Employer False more information

Defined Benefit Plan Surplus Division Adoption Addendum

Form #: DB-007

Product: Defined Benefit
Audience: Employer

F-85 DB, DC, HCSP, 457 Customer Contact Employer False more information

Customer Contact

Form #: F-85

Product: DB, DC, HCSP, 457
Audience: Employer

MD-372 Hybrid Conversion Addendum Employer False more information

Conversion Addendum

Form #: MD-372

Product: Hybrid
Audience: Employer

MD-072 DC Conversion Addendum Employer False more information

Conversion Addendum

Form #: MD-072

Product: DC
Audience: Employer

MD-414 457 Contribution Catch Up Participant False more information

Contribution Catch Up

Form #: MD-414

Product: 457
Audience: Participant

F-50 DB, Hybrid Consent / Authorization: Application for Disability Retirement Participant False more information

Consent / Authorization: Application for Disability Retirement

Form #: F-50

Product: DB, Hybrid
Audience: Participant

DB-013a DB Benefit Change - Permanent or Temporary Employer False more information

Benefit Change - Permanent or Temporary

Form #: DB-013a

Product: DB
Audience: Employer

MD-303 Hybrid Beneficiary Designation Participant False more information

Beneficiary Designation

Form #: MD-303

Product: Hybrid
Audience: Participant

MD-003 DC Beneficiary Designation Participant False more information

Beneficiary Designation

Form #: MD-003

Product: DC
Audience: Participant

MD-403 457 Beneficiary Designation Participant False more information

Beneficiary Designation

Form #: MD-403

Product: 457
Audience: Participant

MD-103 HCSP Beneficiary Designation Participant False more information

Beneficiary Designation

Form #: MD-103

Product: HCSP
Audience: Participant

F-21 DB Beneficiary Change Participant False more information

Beneficiary Change

Form #: F-21
Description:

Defined Benefit participant form for changing or designation of beneficiaries. 


Product: DB
Audience: Participant

6304 Annuity Beneficiary Participant False more information

Beneficiary

Form #: 6304

Product: Annuity
Audience: Participant

F-29 DB Application for Retirement Participant False more information

Application for Retirement

Form #: F-29

Product: DB
Audience: Participant

None GL&D Application for Group Insurance with Under 25 Employees Employer False more information

Application for Group Insurance with Under 25 Employees

Form #: None

Product: GL&D
Audience: Employer

None GL&D Application for Group Insurance Over 24 Employees Employer False more information

Application for Group Insurance Over 24 Employees

Form #: None

Product: GL&D
Audience: Employer

F-51 DB Application for Disability Retirement Employer, Participant False more information

Application for Disability Retirement

Form #: F-51

Product: DB
Audience: Employer, Participant

F-35C DB Alternative Transfer Member Certification for Same Employer Participant False more information

Alternative Transfer Member Certification for Same Employer

Form #: F-35C

Product: DB
Audience: Participant

F-48 DB Alternate Payee (Former Spouse) Benefit Application Participant False more information

Alternate Payee (Former Spouse) Benefit Application

Form #: F-48

Product: DB
Audience: Participant

MD-069 DC Adoption Resolution Employer False more information

Adoption Resolution

Form #: MD-069

Product: DC
Audience: Employer

MD-369 Hybrid Adoption Resolution Employer False more information

Adoption Resolution

Form #: MD-369

Product: Hybrid
Audience: Employer

8513 Annuity Adoption Packet Participant False more information

Adoption Packet

Form #: 8513

Product: Annuity
Audience: Participant

DB-002 DB Adoption Agreement Employer False more information

Adoption Agreement

Form #: DB-002

Product: DB
Audience: Employer

MD-370 Hybrid Adoption Agreement Employer False more information

Adoption Agreement

Form #: MD-370

Product: Hybrid
Audience: Employer

MD-070 DC Adoption Agreement Employer False more information

Adoption Agreement

Form #: MD-070

Product: DC
Audience: Employer

DB-001a DB Admin Order Adopting The MERS Defined Benefit Plan Employer False more information

Admin Order Adopting The MERS Defined Benefit Plan

Form #: DB-001a

Product: DB
Audience: Employer

MD-369b Hybrid Admin Order Adopting MERS Hybrid Employer False more information

Admin Order Adopting MERS Hybrid

Form #: MD-369b

Product: Hybrid
Audience: Employer

MD-069b DC Admin Order Adopting MERS Defined Contribution Plan Employer False more information

Admin Order Adopting MERS Defined Contribution Plan

Form #: MD-069b

Product: DC
Audience: Employer

FN-003 DC, Hybrid, HCSP, 457, RHFV, ISP ACH Debit Request - Automated Transfer Authorization Employer False 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: DC, Hybrid, HCSP, 457, RHFV, ISP
Audience: Employer

None GL&D Accidental Dismemberment Claim Packet Employer False more information

Accidental Dismemberment Claim Packet

Form #: None

Product: GL&D
Audience: Employer

None GL&D Accelerated Benefit Claim Packet Employer False more information

Accelerated Benefit Claim Packet

Form #: None

Product: GL&D
Audience: Employer

MD-413 457 457 In-Plan Roth Conversion Employee False more information

457 In-Plan Roth Conversion

Form #: MD-413

Product: 457
Audience: Employee

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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).