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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
None Employer, Health Care Savings Program, Retiree Health Funding Vehicle, None	HCSP, RHFV	Restated MERS Trust Agreement	Employer	False	Restated MERS Trust Agreement Form #: None Product: HCSP, RHFV 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
F-85 Employer, Defined Benefit, Defined Contribution, 1-99, Health Care Savings Program, Hybrid Plan, 457 Program, Group Life & Disability Insurance, Retiree Health Funding Vehicle, Investment Services Program	DB, DC, HCSP, 457, Hybrid, RHFV	Customer Contact	Employer	False	Customer Contact Form #: F-85 Product: DB, DC, HCSP, 457, Hybrid, RHFV Audience: Employer
MD-372 Employer, Hybrid Plan, MD	Hybrid	Conversion Addendum	Employer	False	Conversion Addendum Form #: MD-372 Product: Hybrid Audience: Employer
MD-072 Employer, Defined Contribution, MD	DC	Conversion Addendum	Employer	False	Conversion Addendum Form #: MD-072 Product: DC 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