Forms → Staff → Benefits → Employee Benefit Plan Enrollment
Form number: 455-20
Audience: MCPS Staff
Last revised: February 2021
Form 450-1 - Optional Employee Term Life Insurance
Form 450-2 - Optional Dependent Term Life Insurance
Form 450-3 - Flexible Spending Account Calendar Year 2021 Election
EMPLOYEE BENEFIT PLAN ENROLLMENT
for Employees With Certain Qualifying Life Events Only
MCPS Forms 450-1, 450-2, 450-3, and 455-20 are to be used only by current MCPS employees who would like to enroll in or make changes to their benefits because they have experienced certain qualifying life events. The qualifying life events for which this form can be used include:
If you have experienced another type of qualifying life event, i.e., birth, adoption, legal guardianship/custody, marriage, divorce/legal separation, loss of non-MCPS coverage, or gain of non-MCPS coverage, visit the Employee Self Service web page and click on the Benefits enrollment or changes due to a qualifying life event link. Log in to make your benefit elections, elect a medical or dependent care flexible spending account, attest to your tobacco-use status, and/or designate life insurance beneficiary(ries).
If you are a new employee enrolling in benefits for the first time, visit the Employee Self Service web page and click on the Benefits enrollment for new employees.
Questions? Contact the Employee and Retiree Service Center at 301-517-8100, Monday through Friday between the hours of 8:00 a.m. and 4:15 p.m., or by e-mail to ERSC@mcpsmd.org.
Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat