Forms

Evangelical Presbyterian Church Region Assignments

  • To find your region, locate the first 3 digits of your Church Zip Code.   If you are a self-paying participant, locate the first 3 digits of your home Zip Code.
  • To view or print click here. 

Medical Enrollment Form

PLEASE NOTE:  ALL HAND WRITTEN FORMS WILL BE RETURNED

Instructions for typing directly onto the form are listed below:

  • Use your tab key or mouse to get to the appropriate fields
  • Click on the appropriate check boxes
  • Tab or use your mouse to get to the next field
  • Print
  • Sign and date
  • Give to your church officer or authorized person to approve
    • Church officer or authorized person will fax or email
      • Fax # and email address are located at the top of the form
  • Click here for the Medical Enrollment Form

Life / LTD Enrollment Form

PLEASE NOTE:   ALL HAND WRITTEN FORMS WILL BE RETURNED

Instructions for typing directly onto the form are listed below:

  • Use your tab key or mouse to get to the appropriate fields
  • Click on the appropriate check boxes
  • Tab or use your mouse to get to the next field
  • Print
  • Sign and date
  • Give to your church officer or authorized person to approve
    • Church officer or authorized person will fax or email
      • Fax # and email address are located at the top of the form
    • Click here for Life & LTD Enrollment Form

Board of Benefits HSA Agreement - Exception Document

Instructions for typing directly onto the form are listed below:

  • Use your tab key or mouse to get to the appropriate fields
  • Print
  • Sign
  • Fax or email to EPC Administration
    • Fax #:  (412) 201-2250
    • Email:  
    • Click here for the Board of Benefits HSA Agreement - Exception Document 

EPC Address and Contact Information Change Form

PLEASE NOTE:   ALL HAND WRITTEN FORMS WILL BE RETURNED

Instructions for typing directly onto the form are listed below: 

  • Click on the appropriate check boxes
  • Use your tab key or mouse to get to the next field
  • Print
  • Sign and date
  • Give a copy to your employer
  • Fax or email to the fax# or email address located at the top of the form
  • Click here for the EPC Address and Contact Information Change Form

Church Retirement Contribution Form-403(b)(9) Retirement Plan

  • To view or print click here (password to open:  molly).

EPC Adoption Agreement

Instructions for typing directly onto the form are listed below:

  • Use the tab key or mouse to get to the appropriate field
  • Click on the appropriate boxes
  • Print, sign and mail, fax or email a copy to EPC Benefits Administration
    • Fax # 734-742-2034
    • Email: 
  • Click here for the EPC Adoption Agreement.

Fidelity Account Application

PLEASE NOTE:    ALL HAND WRITTEN FORMS WILL BE RETURNED

Instructions for typing directly onto the form are listed below:

  • Use your tab key or mouse to get to the appropriate fields
  • Click on the appropriate check boxes
  • Tab or use your mouse to get to the next field
  • Print
  • Sign and date
  • Give to your church officer or authorized person to approve
    • Church officer or authorized person will fax or email
      • Fax # and email address are located at the top of the form
  • Click here for the Fidelity Account Application Form

Fidelity Beneficiary Form

PLEASE NOTE:    ALL HAND WRITTEN FORMS WILL BE RETURNED

Instructions for typing directly onto the form ar elisted below:

  • Use your tab key or mouse to get to the appropriate fields
  • Click on the appropriate check boxes
  • tab or use your mouse to get to the next field
  • print
  • Sign and date
  • Give to your church officer or authorized person to approve
    • church officer or authorized person will fax or email
      • Fax # and email address are located at the top of the form
  • Click here for the Fidelity Beneficiary Form

Salary Reduction and Termination Form

Investment Options Guide