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Employee Benefits Selection

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

This form should be used by new employees, or employees eligible through a Qualifying Life Event, to submit all documentation for benefits selected for the 2025-2026 school year.

Key Information:
  • Documentation: It is important that you submit all documentation to record your benefit elections by using this form. If the appropriate documents are not submitted, there may be a delay in obtaining the benefits selected.
  • All new employees have 30 days from their hire date to elect benefits. If benefits are not selected during this time, the new employee will have to wait until Open Enrollment to select benefits.
  • The only exception to this rule is if the employee has a Qualifying Life Event. Qualifying Life Events must be submitted within 30 days of the event. Qualifying Life Events are listed in the first few pages of the Benefits Guide.
  • Please note that the Benefits Election Form only tells us which benefits you are electing. You still need to complete the corresponding enrollment form to enroll. 
Things to keep in mind while filling out these documents:
  • You will need your marriage certificate when adding a spouse.
  • You will need your child's birth certificate if you are adding a child to your benefits.
  • If you are choosing an HMO plan with either Blue Cross Blue Shield or Harvard Pilgrim, you are required to select a PCP.
Remember to schedule a one-on-one meeting with a benefits counselor to discuss all benefits. These sessions are the best way to ensure you fully understand your options and make the most informed decisions for yourself and your family. Take time to make the best decisions for you and your family during this important period.
 

If you have any questions, please contact the HR Department.

Required fields marked with an asterisk *

School/Location*
Answer required for "School/Location"
Which Health Benefit are you enrolling in? (select all that apply)*
Answer required for "Which Health Benefit are you enrolling in? (select all that apply)"
Please indicate whether your plan will be an HMO or PPO
Answer required for "Please indicate whether your plan will be an HMO or PPO"
Are you currently covered by health/dental insurance?*
Answer required for "Are you currently covered by health/dental insurance?"
Upload Attachment/JPEG*
Please attach appropriate enrollment forms.
Answer required for "Upload Attachment/JPEG"
or drag it here.
Upload Attachment/JPEG*
Please attach supporting documents (i.e. birth certificates, marriage certificates, etc.)
Answer required for "Upload Attachment/JPEG"
or drag it here.
Coverage Letter
Upload coverage letter if currently covered by another insurance.
Answer required for "Coverage Letter"
or drag it here.
Confirmation Email