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MERS Forms

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Abbreviations

DB = Defined Benefit, DC = Defined Contribution, DC+ = Defined Contribution Plus, 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.

Employer

Form #	Product	Name	Audience	myMers	Info
None Employer, Group Life & Disability Insurance, None	GL&D	Waiver of Premium Claim Packet	Employer	False	Waiver of Premium Claim Packet Form #: None Product: GL&D Audience: Employer
MD-469 Employer, 457 Program, MD	457	Uniform Resolution	Employer	False	Uniform Resolution Form #: MD-469 Description: test def. Product: 457 Audience: Employer
MD-169 Employer, Health Care Savings Program, MD	HCSP	Uniform Resolution	Employer	False	Uniform Resolution Form #: MD-169 Product: HCSP Audience: Employer
RH-669 Employer, Retiree Health Funding Vehicle, RH	RHFV	Uniform Resolution	Employer	False	Uniform Resolution Form #: RH-669 Product: RHFV Audience: Employer
DB-004 Employer, Defined Benefit, DB	DB	Service Credit Purchase Opt-Out Form	Employer	False	Service Credit Purchase Opt-Out Form Form #: DB-004 Product: DB Audience: Employer
DB-001c Employer, Defined Benefit, Defined Contribution, Health Care Savings Program, Hybrid Plan, 457 Program, Retiree Health Funding Vehicle, Investment Services Program, DB, Defined Contribution Plus	DB, DC, HCSP, 457, Hybrid, RHFV, ISP	Resolution Establishing Authorized Signatories for MERS Contracts and Service Credit Purchase Approvals	Employer	False	Resolution Establishing Authorized Signatories for MERS Contracts and Service Credit Purchase Approvals Form #: DB-001c Product: DB, DC, HCSP, 457, Hybrid, RHFV, ISP Audience: Employer
DB-001b Employer, Defined Benefit, DB	DB	Resolution Adopting The MERS Defined Benefit Plan	Employer	False	Resolution Adopting The MERS Defined Benefit Plan Form #: DB-001b Product: DB Audience: Employer
None Employer, Group Life & Disability Insurance, None	GL&D	Request for Life Conversion Materials	Employer	False	Request for Life Conversion Materials Form #: None Product: GL&D Audience: Employer
F-79 Employer, Defined Benefit, Defined Contribution, 1-99, Hybrid Plan	DB, DC, Hybrid	Reciprocal Units (Act 88) - Resolution	Employer	False	Reciprocal Units (Act 88) - Resolution Form #: F-79 Product: DB, DC, Hybrid Audience: Employer
F-54 Participant, Employer, Defined Benefit, 1-99, Disability	DB	Psychiatric Medical Report	Employer, Participant	False	Psychiatric Medical Report Form #: F-54 Product: DB Audience: Employer, Participant
2160 Employer, Group Life & Disability Insurance, None	GL&D	Proposal Process & Data Checklist	Employer	False	Proposal Process & Data Checklist Form #: 2160 Product: GL&D Audience: Employer
DB-013b Employer, Defined Benefit, Defined Contribution, 1-99, Hybrid Plan	DB, DC, Hybrid	Projection Study	Employer	False	Projection Study Form #: DB-013b Product: DB, DC, Hybrid Audience: Employer
F-53 Participant, Employer, Defined Benefit, 1-99, Disability	DB	Physician's Statement of Disability	Employer, Participant	False	Physician's Statement of Disability Form #: F-53 Product: DB Audience: Employer, Participant
DB-002c Employer, Defined Benefit, 1-99	DB	Part-Time to Full-Time Service Credit Conversion	Employer	False	Part-Time to Full-Time Service Credit Conversion Form #: DB-002c Product: DB Audience: Employer
MD-170 Employer, Health Care Savings Program, MD	HCSP	Participation Agreement	Employer	False	Participation Agreement Form #: MD-170 Product: HCSP Audience: Employer
MD-470 Employer, 457 Program, MD	457	Participation Agreement	Employer	False	Participation Agreement Form #: MD-470 Product: 457 Audience: Employer
MD-071 Employer, Defined Contribution, MD	DC	MERS Loan Addendum	Employer	False	MERS Loan Addendum Form #: MD-071 Product: DC Audience: Employer
F-05 Participant, Employer, Defined Benefit, Enrollment Kits, 1-99	DB	Membership Application	Employer, Participant	False	Membership Application Form #: F-05 Description: test summary Product: DB Audience: Employer, Participant
None Employer, Group Life & Disability Insurance	GL&D	Medical History Statement	Employer	False	Medical History Statement Form #: None Product: GL&D Audience: Employer
MD-073 Employer, Defined Contribution, Hybrid Plan, MD, Defined Contribution Plus	DC	Matching Employer Contribution Addendum	Employer	False	Matching Employer Contribution Addendum Form #: MD-073 Product: DC Audience: Employer
MD-010 Participant, Employer, Defined Contribution, MD	DC	Loan Application	Participant	False	Loan Application Form #: MD-010 Product: DC Audience: Participant
MD-371 Employer, Hybrid Plan, MD	Hybrid	Loan Addendum	Employer	False	Loan Addendum Form #: MD-371 Product: Hybrid Audience: Employer
MD-471 Employer, 457 Program, MD	457	Loan Addendum	Employer	False	Loan Addendum Form #: MD-471 Product: 457 Audience: Employer
None Employer, Group Life & Disability Insurance, None	GL&D	Life Insurance Portability	Employer	False	Life Insurance Portability Form #: None Product: GL&D Audience: Employer
None Employer, Group Life & Disability Insurance, None	GL&D	Life Insurance Enrollment / Change	Employer	False	Life Insurance Enrollment / Change Form #: None Product: GL&D Audience: Employer
None Employer, Group Life & Disability Insurance, None	GL&D	Life Insurance Benefits Claim Packet	Employer	False	Life Insurance Benefits Claim Packet Form #: None Product: GL&D Audience: Employer
MD-300 Participant, Employer, Enrollment Kits, Hybrid Plan, None	Hybrid	Enrollment Kit	Employer, Participant	False	Enrollment Kit Form #: MD-300 Product: Hybrid Audience: Employer, Participant
MD-100 Participant, Employer, Enrollment Kits, Health Care Savings Program, None	HCSP	Enrollment Kit	Employer, Participant	False	Enrollment Kit Form #: MD-100 Product: HCSP Audience: Employer, Participant
MD-400 Participant, Employer, Enrollment Kits, 457 Program, MD	457	Enrollment Kit	Employer, Participant	False	Enrollment Kit Form #: MD-400 Product: 457 Audience: Employer, Participant
MD-000 Participant, Employer, Defined Contribution, Enrollment Kits, None	DC	Enrollment Kit	Employer, Participant	False	Enrollment Kit Form #: MD-000 Product: DC Audience: Employer, Participant
MD-700 Participant, Employer, Enrollment Kits, MD, Defined Contribution Plus	DC+	Enrollment Kit	Employer, Participant	False	Enrollment Kit Form #: MD-700 Product: DC+ Audience: Employer, Participant
DB-094 Employer, Defined Benefit, DB	DB	Employer Resolution Establishing Uniform Transfer Provision	Employer	False	Employer Resolution Establishing Uniform Transfer Provision Form #: DB-094 Description: Employer form: Defined Benefit Uniform Transfer form. DB-094 Product: DB Audience: Employer
MD-473 Employer, 457 Program, MD	457	Employer Contribution Addendum	Employer	False	Employer Contribution Addendum Form #: MD-473 Product: 457 Audience: Employer
F-17 Employer, Defined Benefit, 1-99	DB	Employee Census	Employer	False	Employee Census Form #: F-17 Product: DB Audience: Employer
MD-474 Employer, 457 Program, MD	457	Eligible Automatic Contribution Arrangement (EACA) Addendum	Employer	False	Eligible Automatic Contribution Arrangement (EACA) Addendum Form #: MD-474 Product: 457 Audience: Employer
MD-505 Employer, Investment Services Program, MD	ISP	Distribution	Employer	False	Distribution Form #: MD-505 Product: ISP Audience: Employer
None Employer, Group Life & Disability Insurance, None	GL&D	Disability Claim Packet	Employer	False	Disability Claim Packet Form #: None Product: GL&D Audience: Employer
DB-007 Employer, Defined Benefit, DB	DB	Defined Benefit Plan Surplus Division Adoption Addendum	Employer	False	Defined Benefit Plan Surplus Division Adoption Addendum Form #: DB-007 Product: DB Audience: Employer
MD-072 Employer, Defined Contribution, MD	DC	Conversion Addendum	Employer	False	Conversion Addendum Form #: MD-072 Product: DC Audience: Employer
MD-372 Employer, Hybrid Plan, MD	Hybrid	Conversion Addendum	Employer	False	Conversion Addendum Form #: MD-372 Product: Hybrid Audience: Employer
DB-013a Employer, Defined Benefit, DB	DB	Benefit Change - Permanent or Temporary	Employer	False	Benefit Change - Permanent or Temporary Form #: DB-013a Product: DB Audience: Employer
None Employer, Group Life & Disability Insurance, None	GL&D	Application for Group Insurance with Under 25 Employees	Employer	False	Application for Group Insurance with Under 25 Employees Form #: None Product: GL&D Audience: Employer
None Employer, Group Life & Disability Insurance, None	GL&D	Application for Group Insurance Over 24 Employees	Employer	False	Application for Group Insurance Over 24 Employees Form #: None Product: GL&D Audience: Employer
F-51 Participant, Employer, Defined Benefit, 1-99, Disability	DB	Application for Disability Retirement	Employer, Participant	False	Application for Disability Retirement Form #: F-51 Product: DB Audience: Employer, Participant
MD-369 Employer, Hybrid Plan, MD	Hybrid	Adoption Resolution	Employer	False	Adoption Resolution Form #: MD-369 Product: Hybrid Audience: Employer
MD-069 Employer, Defined Contribution, MD	DC	Adoption Resolution	Employer	False	Adoption Resolution Form #: MD-069 Product: DC Audience: Employer
MD-070 Employer, Defined Contribution, MD	DC	Adoption Agreement	Employer	False	Adoption Agreement Form #: MD-070 Product: DC Audience: Employer
MD-370 Employer, Hybrid Plan, MD	Hybrid	Adoption Agreement	Employer	False	Adoption Agreement Form #: MD-370 Product: Hybrid Audience: Employer
DB-002 Employer, Defined Benefit, DB	DB	Adoption Agreement	Employer	False	Adoption Agreement Form #: DB-002 Product: DB Audience: Employer
DB-001a Employer, Defined Benefit, DB	DB	Admin Order Adopting The MERS Defined Benefit Plan	Employer	False	Admin Order Adopting The MERS Defined Benefit Plan Form #: DB-001a Product: DB Audience: Employer
MD-369b Employer, Hybrid Plan, MD	Hybrid	Admin Order Adopting MERS Hybrid	Employer	False	Admin Order Adopting MERS Hybrid Form #: MD-369b Product: Hybrid Audience: Employer
MD-069b Employer, Defined Contribution, MD	DC	Admin Order Adopting MERS Defined Contribution Plan	Employer	False	Admin Order Adopting MERS Defined Contribution Plan Form #: MD-069b Product: DC Audience: Employer
FN-003 Employer, Defined Contribution, Health Care Savings Program, Hybrid Plan, 457 Program, Retiree Health Funding Vehicle, Investment Services Program, FN	DC, Hybrid, HCSP, 457, RHFV, ISP	ACH Debit Request - Automated Transfer Authorization	Employer	False	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 Employer, Group Life & Disability Insurance, None	GL&D	Accidental Dismemberment Claim Packet	Employer	False	Accidental Dismemberment Claim Packet Form #: None Product: GL&D Audience: Employer
None Employer, Group Life & Disability Insurance, None	GL&D	Accelerated Benefit Claim Packet	Employer	False	Accelerated Benefit Claim Packet Form #: None Product: GL&D Audience: Employer