Benefit Plan Forms
The information you provide to us on each form is important. Please print legibly, or type directly on each Microsoft Word form. Please note that your insurance Enrollment Form needs to have an authorized person's approval, if applicable. Please submit all forms to the mailing address, fax number, or email address on the form.
ADDRESS AND/OR CONTACT INFORMATION UPDATE FORM
Click here to download the form required to make any changes to your address or other contact information that we have on file.
BENEFITS ENROLLMENT/CHANGE FORM
Click here to download the EPC Benefits Enrollment/Change Form to enroll new participants into the Medical, Life, Long-Term Disability, Dental, and Vision plans. For insurance(s), the date of eligibility depends on whether the employee is currently insured:
- For a new hire transferring from another Plan, coverage will commence the day following termination of coverage from their previous plan.
- For a new hire not transferring from another plan, EPC insurance benefits will begin on the first day of the month following the date of hire.
- If you are a new employee to the EPC, contact your church administrator to learn what EPC benefits are offered from the options available.
QUALIFYING LIFE EVENT/FAMILY CHANGES
A Qualified Life Event is a change in your family status or employment that affects your benefits eligibility. Examples include marriage; birth or adoption; divorce or separation; a dependent child aging out of benefits at age 26; gain or loss of a spouse’s health coverage; or a spouse’s employer offering benefits with a different Open Enrollment period.
If you experience a Qualified Life Event, you must notify the EPC Benefits Administration Office and request benefit changes within 30 days of the event. Click here to download the EPC Benefits Enrollment/Change Form.
BENEFITS TERMINATION REPORT
Click here to download the termination report, necessary to remove a participant from the EPC Benefits Plans.
TERM LIFE/AD&D/LTD PARTICIPANT FORM
Click here for the Hartford Beneficiary Designation form, which designates your beneficiaries for your Hartford Life and AD&D policy. Please print legibly or type directly on the editable pdf document. Please note that your Enrollment Form needs to have an authorized person's approval, if applicable. Please submit completed form to the mailing address, fax number, or email address on the form.
BENEFITS PREMIUM PAYMENT COUPON
Click here to download the payment coupon for Medical, Life Insurance, and Long-Term Disability insurance premiums.
BOARD OF BENEFITS HSA AGREEMENT—EXCEPTION DOCUMENT (OPT-OUT)
Click here to download the Board of Benefits HSA Agreement—Exception document to opt out of the HSA Plan. Complete and return by email at firstname.lastname@example.org or fax to (412) 224-4465.
FIDELITY 403(b)(9) ACCOUNT APPLICATION AND BENEFICIARY FORM
Click here to download the Fidelity 403(b)(9) Retirement Account Application Form. A completed form is required to open a new account. Note that this form is not a fillable pdf; it will need to be printed and filled out by hand.
Click here to complete your application online. Once you’ve completed your enrollment, print your confirmation page and submit this to your church administrator. Church Administrators: please contact Diane Pray when you have completed this process.
FIDELITY TRANSFER/ROLLOVER/EXCHANGE FORM
Click here to download the Transfer/Rollover/Exchange form for moving assets from another investment provider to an EPC-sponsored Fidelity retirement account. You can also use this form to consolidate multiple employer-sponsored retirement accounts currently held at Fidelity. Instructions for completing the form are included.
EPC ADOPTION AGREEMENT
Click here to download the 403(b)(9) Adoption Agreement Form.
CHURCH BENEFITS ELECTION FORM
Click here to download the form required to select those benefits you will offer to your staff. The EPC Administration Office must have this completed form on file for employees of your church to enroll in the EPC Benefit Plans.
403(b)(9) RETIREMENT CONTRIBUTION FORM
Click here to download the Retirement Plan Contribution Form in Excel spreadsheet format. Please note that we do not invoice for retirement contributions.
EMPLOYEE CONTRIBUTIONS SALARY REDUCTION AND/OR TERMINATION FORM
Click here to download the Salary Reduction Form for voluntary additional retirement contributions.
Information provided in this web site does not constitute legally binding advice. EPC benefits are subject to the provisions of the Wrap, Medical Plan, and Retirement Plan documents available on this website or in print from EPC Benefits, P.O. Box 6412, Plymouth, MI 48170. For more information, contact EPC Benefits at (734) 838-6942 or fax (734) 742-2034.