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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