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DOCUMENTS, FORMS, AND NOTICES

The information you provide to us on each form is important. Most of these forms are fillable pdf documents, which you can type directly into by saving to your computer, then opening in Adobe Acrobat. If you prefer, you can fill them out by hand, but please print legibly. Also 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.

Use these quick links to navigate to the appropriate section:

BENEFITS DOCUMENTS AND NOTICES

BENEFIT PLAN DOCUMENT (WRAP)

This document provides the information about the EPC Benefits Plan as required by the Employee Retirement Income Security Act of 1974 (ERISA). Click here to download the 2018 Benefit Plan document in pdf format.

MEDICAL PLAN DOCUMENT

The Medical Plan summary constitutes the terms and conditions of your medical and pharmacy coverage. Click here to download the 2018 Medical Plan summary document in pdf format.

SUMMARY OF BENEFITS AND COVERAGE (SBC) DOCUMENTS

Click on the appropriate Plan option below to download the SBC in pdf format. Click here for information from the United States Department of Labor about SBC compliance regulations.

2018 Platinum
2018 Gold
2018 Gold HDHP (also known as HSA)
2018 Silver

PREVENTIVE SCHEDULE

Click here to download the most recent EPC Medical Plan Preventive Schedule in pdf format.

GOLD HDHP (HEALTH SAVINGS ACCOUNT) OPTION

Click here for information about the Gold HDHP Plan, our high-deductible health plan/health savings account option. HDHP plans are also known as HSA (Health Savings Account) plans.

Click here for a handy quickstart guide to starting an HSA.

NOTICE OF PRIVACY PRACTICE

Click here to download the most recent Notice of Privacy Practice in pdf format.

PRESCRIPTION PLAN MAIL ORDER INFORMATION

Click here for information about our Prescription Plan mail order service.

PHARMACY PLAN DOCUMENTS

Click here for a summary of the benefits of the Pharmacy Plan.
Click here for the detailed Pharmacy Plan document.

CREDITABLE COVERAGE LETTER

Click here to download the Creditable Coverage Letter regarding prescription drug coverage and Medicare.

HEALTH REIMBURSEMENT ARRANGEMENT (HRA) PLAN DOCUMENT

Click here to download the HRA Plan Document. Please note that if a church is providing any kind of medical reimbursement, it is required to have an HRA in place. The Plan (and document) is provided by the EPC for the benefit of individual EPC churches and is not an EPC Plan.

HEALTH REIMBURSEMENT ARRANGEMENT (HRA) ADOPTION AGREEMENT

Click here to download the HRA Adoption Agreement document that can be used if you choose to utilize this Plan.

HEALTH REIMBURSEMENT ARRANGEMENT (HRA) FAQ

Click here to download answers to common questions about an HRA and this Plan.

DENTAL PLAN BOOKLETS

These booklets highlight the benefits provided under the EPC Dental Plans and provide both quick access to the information you will most often want to review, and detailed explanation of your benefits and any limitations or restrictions that might apply.

Click here to download the Low Plan booklet.
Click here to download the High Plan booklet.

TERM LIFE AND AD&D PLAN HANDBOOK

Click here to download the Term Life and AD&D Plan Handbook, provided by Hartford Life and Accident Insurance Company.

LONG-TERM DISABILITY PLAN HANDBOOK

Click here to download the Long-Term Disability Plan Handbook, provided by Hartford Life and Accident Insurance Company.

RETIREMENT DOCUMENTS AND NOTICES

FIDELITY INVESTMENTS OPTIONS

Visit www.netbenefits.com/EPC for more information on retirement and the Fidelity investment options available (to view the investment options, click on “Plan and Investments” and then “Investment Options”). Target Retirement Date funds and Core Funds that are available in the EPC Plan, along with their performances, are listed.

If you prefer a hard copy, click here for a printable, 18-page booklet in pdf format. Or you also can speak with a Fidelity representative by calling Fidelity directly at (800) 343-0860.

INVESTMENT POLICY STATEMENT

Click here to download an outline of general investment policies as adopted by the Board of Benefits, effective January 2017. This document provides guidance to the investment advisory firm in determining and implementing investment decisions.

DEFINED RETIREMENT CONTRIBUTION PLAN

Click here to download the terms and conditions that apply with respect to assets held in the Code Section 403(b)(9) retirement income account program.

PARTICIPANT FORMS

The information you provide to us on each form is important. Most of these forms are fillable pdf documents, which you can type directly into by saving to your computer, then opening in Adobe Acrobat. If you prefer, you can fill them out by hand, but please print legibly. Also 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 FORM

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.

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 epc@cdsadmin.com 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 and Beneficiary Designation 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 Rebeca Santana at benefits@epc.org when you have completed this process.

FIDELITY 403(b)(9) BENEFICIARY DESIGNATION FORM

Click here to download the Fidelity 403(b)(9) Retirement Account Beneficiary Designation Form. Note that this form is not a fillable pdf; it will need to be printed, filled out by hand, signed, and returned to the address on the form.

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.

FIDELITY RETIREMENT PLAN DISTRIBUTION FORM

Click here to download the Distribution Form for all participants in the Fidelity Retirement Plan. In addition, the form is specifically customized to allow a retired EPC-ordained pastor to request tax-free housing withdrawals.

Click here for instructions on completing the Distribution Form.

EMPLOYER FORMS

The information you provide to us on each form is important. Most of these forms are fillable pdf documents, which you can type directly into by saving to your computer, then opening in Adobe Acrobat. If you prefer, you can fill them out by hand, but please print legibly. Also 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.

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.

TERM LIFE/AD&D/LTD SALARY UPDATE FORM

Click here to download the Salary Update Form to update salary information for Term Life, AD&D, and LTD benefits participants.

EMPLOYEE CONTRIBUTIONS SALARY REDUCTION 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 Medical Plan and Retirement Plan documents available on this web site or in print from EPC Benefit Resources, Inc. (BRI), 5850 T.G. Lee Blvd., Suite 510, Orlando FL 32822. For more information, contact BRI at benefits@epc.org or 407-930-4492 (voice and fax).

Office of the General Assembly
5850 T.G. Lee Blvd., Suite 510
Orlando, FL 32822
407-930-4239
407-930-4247 (fax)
info@epc.org

OGA Staff Contacts