FormsStaffBenefits → Employee Benefit Plan Enrollment

Employee Benefit Plan Enrollment

for Employees With a Qualifying Life Event Only

About this Form

Form number: 455-20

Audience:  MCPS Staff

Last revised: August 2021

Related Forms

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

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 e-mail an electronically signed Adobe PDF to ERSC@mcpsmd.org. Please do not mail copies to ERSC once you have faxed or e-mailed 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

Adobe PDF Employee Benefit Plan Enrollment
for Employees With a Qualifying Life Event Only
166 KEnglish

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