MCPS FORMS > STAFF FORMS > Employee Benefit Plan Enrollment

Employee Benefit Plan Enrollment

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 file 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 e-mailed to you. Unsigned forms will be returned to you and become your responsibility to resubmit to ERSC by the appropriate deadline.

• This form is for: MCPS Employees
• Form number: 455-20
• Last revised: October 2011

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