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. 

EPC - MEDICAL, LIFE & LTD PAYMENT COUPON

  • Please use a payment coupon when submitting Medical, Life & LTD premium payments.

  • Please complete all information on coupon before submitting.  To view or print payment coupon click here.

EPC - TERMINATION REPORT (MEDICAL, LIFE & LTD)

MEDICAL ENROLLMENT FORM

PLEASE NOTE:  ALL HAND WRITTEN FORMS WILL BE RETURNED

PLEASE NOTE 2013 MEDICAL ENROLLMENT ELIGIBILITY REQUIREMENT UPDATE:

For Health Insurance, date of eligibility depends on whether the employee is currently insured.

  • For New Hire, transferring from another Plan
    • For an employee who transfers from other medical plans and meets the eligibility criteria to participate in the EPC Medical Plan, coverage will commence the day following termination of coverage from their previous plan.
  • For New Hire, not transferring from another Plan
    • If the employee's first payroll period begins on the first calendar day of the month, coverage will commerce on that day if the employee is at work on the first scheduled work day on or after such day.
    • If the employee's first payroll period begins after the first calendar day of the month, the employee must complete the employment Waiting period from the beginning day of the first payroll period to the first day of the following month.  A "Waiting Period" is the time between the first day of employment and the first day of coverage under the Plan.  The Waiting period is counted in the Pre-existing conditions exclusion time.  And,
  • Is in a class eligible for coverage.

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.

EPC CERTIFICATION FORM

This form is to be completed by all churches enrolling in the Medical, Life & LTD Benefit Plan for the first time.

Instructions for typing directly onto the form are listed below:

  • Use your tab key or mouse to get to the appropriate fields
  • tab or use your mouse to get to the next field
  • Print
  • Sign and date
  • Fax to Billing Administration with any enrollment forms to fax #(412) 201-2250.
  • Click here for the EPC Certification Form.

Life / LTD ENROLLMENT FORM

PLEASE NOTE 2013 LIFE & LTD ENROLLMENT ELIGIBILITY REQUIREMENT UPDATE:

For the Life Insurance / LTD Plan, a person is eligible for Employee coverage on the first day of employment.

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.
    • Click here to complete and attach to your Life Enrollment Beneficiary form if you have more than 2 Secondary Beneficiaries to list.

BOARD OF BENEFITS HSA AGREEMENT - EXCEPTION DOCUMENT (OPT OUT)

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 (PARTICIPANT)

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
      • Fax # (734) 742-2034
  • 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
      • Fax # (734)742-2034
  • Click here for the Fidelity Beneficiary Form

SALARY REDUCTION AND TERMINATION FORM

  • Complete and submit to your payroll department.  To view or print click here. 

INVESTMENT OPTIONS GUIDE