Editing previous response:

Please fix the highlighted areas below before submitting.

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

Last Name*

Answer Required

Email Address*

Answer Required

Employee ID Number

Answer Required

School/Location*

Answer Required

Which Health Benefit do you need assistance with?

Answer Required

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

Upload Attachment/JPEG

This is optional

Answer Required

Choose a file or drag it here.

FOR INTERNAL USE ONLY

EPS Human Resources Department

Answer Required

Confirmation Email

Confirmation Email *

Email Required