Employee Benefit Plan Enrollment

for Employees With a Qualifying Life Event Only

Complete both sides, sign, and return to the Employee and Retiree Service Center (ERSC). This form must be signed at the bottom of pages 1 and 2. You may fax enrollment forms to 301-279-3642/301-279-3651 or email an electronically signed Adobe PDF to  ERSC@mcpsmd.org. Please do not mail copies to ERSC once you have faxed or emailed the enrollment form. A confirmation of your requested change(s) will be sent to you. Unsigned forms will be returned to you and will become your responsibility to resubmit to ERSC by the appropriate deadline. Please see the Employee Benefit Summary (EBS) for deadline information.

Employee Benefit Plan Enrollment for Employees With a Qualifying Life Event Only

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