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Employee Benefit Plan Enrollment

for Employees With a Qualifying Life Event Only

About this Form

Form number: 455-20

Audience:  MCPS Staff

Last revised: November 2017

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 2018 Election

INSTRUCTIONS:

MCPS Forms 450-1, 450-2, 450-3, and 455-20 are only for current MCPS employees who have experienced a qualifying life event, or are returning from long-term leave and would like to enroll in, or make changes to, their benefits.

If you are a new employee enrolling in benefits for the first time, visit the Employee Self Service web page and click on the Benefits enrollment for new employees link to make your benefit elections, elect a medical or dependent care flexible spending account, attest to your tobacco-use status, and/or designate life insurance beneficiary(ries).

Questions? Contact the Employee and Retiree Service Center at 301-517-8100, Monday through Friday between the hours of 8:00 a.m. and 4:15 p.m., or by e-mail to ERSC@mcpsmd.org.

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

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