Forms

We respectfully request you type or print legibly on all forms. 

To type directly onto the form:

  • 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, if applicable
  • You, a church officer, or authorized person will fax or email.
  • Fax number and email address are located at the top of the form.

EPC - ADOPTION AGREEMENT, this is to be completed by all EPC churches.

  • Print and sign. Then mail, fax, or email a copy to EPC Benefits Administration
  • Fax: 734-742-2034
  • Email:
  • Click here for the EPC Adoption Agreement.

EPC - 2014 MEDICAL, LIFE & LTD PAYMENT COUPON

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

  • Please complete all information on coupon before submitting. Click here to view or print payment coupon.

EPC - TERMINATION REPORT (MEDICAL, LIFE, LTD, DENTAL, VISION)

EPC 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 - CREDITABLE COVERAGE LETTER 2014 - RE: PRESCRIPTION DRUG COVERAGE AND MEDICARE

EPC - MEDICAL ENROLLMENT

PLEASE NOTE: 2015 MEDICAL ENROLLMENT ELIGIBILITY REQUIREMENT:

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
    • An employees medical plan benefits will begin the first of the month, following their date of hire. 

2014 EPC Medical Enrollment Form: Click here.

2015 EPC Medical Enrollment Form: Click here.

Qualifying 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. Should an employee experience a Qualified Life Event, you must notify the EPC Benefits Administration Office and request benefit changes within 30 days of the event.

LIFE/ LTD ENROLLMENT FORM & BENEFICIARY UPDATE FORM

  • Click here for 2014 Life and LTD Enrollment Form
  • EPC Class Definition:
    • Class 1: EPC Ordained
    • Class 2: Ordained Employees, other than EPC Ordained
    • Class 3: Management, excluding Ordained Employees
    • Class 4: Salaried Employees, excluding Management and Ordained
    • Class 5: Hourly employees, excluding Management and Ordained
  • Click here to complete and attach to your 2014 Life Enrollment Beneficiary form if you have more than 2 Primary Beneficiaries to list.
  • Click here to complete and attach to your 2014 Life Enrollment Beneficiary form if you have more than 2 Secondary Beneficiaries to list.
  • Click here to update your Life Insurance Beneficiary designation.

UPDATE: PLEASE NOTE 2015 LIFE AND LTD ENROLLMENT ELIGIBILITY REQUIREMENT CHANGE:

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

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

  • Fax or email to EPC Benefits Administration
  • Fax: (412) 201-2250
  • Email:
  • Click here for the Board of Benefits HSA Agreement - Exception Document 

EPC  - EMPLOYEE ADDRESS AND CONTACT INFORMATION CHANGE FORM

  • Click here for the EPC Address and Contact Information Change Form

EPC - CHURCH RETIREMENT CONTRIBUTION FORM-403(b)(9) RETIREMENT PLAN

  • Complete and submit along with the retirement contribution check to: 
    • EPC Retirement
    • Dept. 2023
    • P.O. Box 30516
    • Lansing, MI  48909
  • Click here to view, download or print the Church Retirement Contribution form (PASSWORD TO OPEN: molly).

FIDELITY ACCOUNT APPLICATION AND BENEFICIARY FORM

  • Fax your competed four-page form to: (734) 742-2034
  • Click here for the Fidelity Account Application Form
  • Click here for the Fidelity Beneficiary Form
  • Click here for the Fidelity Investments Guide (Revised Nov 2013)

SALARY REDUCTION (EMPLOYEE CONTRIBUTIONS) AND/OR TERMINATION  OF CONTRIBUTIONS FORM

  • Click here for the EPC Salary Reduction Form.
  • Complete and submit to your Payroll Department.