PIBF FORMS


*Click on the form name to view or download.


1: PIBF Fund Claim Form



4: PIBF Member Address or Contact Change Form

Click HERE to submit a change of Address in the Member’s Only section of the PIBF website.


5: PIBF Census Data Form


6: Coordination Of Benefits Form


7: Dependent Affidavit Form


For Dependent Young Adults Ages 19 – 26.

8: Special Open Enrollment Form (age 19-26)

9: Coordination of Benefits Form (age 19-26)


10: Health Reimbursement Arrangement – HRA


11: Change Of Beneficiary – PIBF Death Benefit


12: Claimant Statement Form – Death Benefit


13: Release Of Medical Information Form


14: CVS Caremark RX Reimbursement Form


15: Appointment of Authorized Representative Form (For Appeal Procedure)


16: Retiree Health Insurance Premium
Authorization Agreement For Automatic Deduction


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