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Health Benefits Assistance Request

EPS logo, wavy design in crimson and gold
HUMAN RESOURCES DEPARTMENT

This form should be used anytime you have questions about or need assistance with your current Health Benefits.

This form should not be used to enroll in any Health Benefits.

Required fields marked with an asterisk *

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Email Address*

Answer required for "Email Address"

Employee ID Number

Answer required for "Employee ID Number"

School/Location*

Answer required for "School/Location"

Which Health Benefit do you need assistance with?

Answer required for "Which Health Benefit do you need assistance with?"

Blue Cross Blue Shield

Harvard Pilgrim

Delta Dental

Teamsters Dental

Other:

Please describe what issue you're experiencing or any questions you may have.*

Answer required for "Please describe what issue you're experiencing or any questions you may have."

Upload Attachment/JPEG

This is optional

Answer required for "Upload Attachment/JPEG"

Choose a file or drag it here.

FOR INTERNAL USE ONLY

EPS Human Resources Department

Answer required for "FOR INTERNAL USE ONLY"

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"