HOMEABOUT USSCHOOLSCOMMUNITYFOR PARENTSFOR STUDENTSFOR STAFF

> Staff Use


> Student/Parent Use

> Activities
> Bullying
> Cooperative Education Program
> Enrollment/Records
> Health
> Home Instruction
> National Academy
Foundation Programs
> Student Service Learning
> Student Vehicle
> Summer School

> Public Use

> ADA Accommodations
> Bidder's List
> Complaint
> Data Request
> Employment
> Research Activity

> Forms Register


> Related Pages

> MCPS Policies &
Regulations Handbook
> Office of Shared
Accoutability


Employee Benefit Plan Enrollment

INSTRUCTIONS: 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 e-mailed 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.

  • This form is for: MCPS Employees
  • Form number: 455-20
  • Last revised: September 2013
Name
PDF Size
Form Number
Employee Benefit Plan Enrollment 2014 560 K 455-20

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat

 

For questions regarding forms, call Harriet Potosky at (301) 279-3538.

Updated November 21, 2013 | Maintained by Missy Gumula
HOME | PARENTS | STUDENTS | STAFF | ABOUT | SCHOOLS | COMMUNITY | BOARD OF ED | TOP up arrow
©1995–2011 Montgomery County Public Schools, 850 Hungerford Drive, Rockville, Maryland 20850
Contact | Privacy | Nondiscrimination/ADA | Get Acrobat | Get Flash | Montgomery County