PIBF Forms

PIBF Fund Claim Form

Click The Above Link To Download a PIBF Fund Claim Form.

PIBF Member Address or Contact Change Form

Click The Above Link To Download a Address Or Contact Change Form. 

PIBF Census Data Form

Click The Above Link To Download a Census Data Form. 

Coordination Of Benefits Form

Click The Above Link To Download a COB Form.

Dependent Affidavit Form

Contact PIBF With Questions In Regard To This Form.

Retiree Health Insurance Premium
Authorization Agreement For Automatic Deduction Form

To Start Or Change The Automatic Monthly Retraction Of H&W Insurance Premium Download The Above Form.

Health Reimbursement Arrangement (HRA) Form

You have until March 31 of the following year to file for HRA reimbursement on out of pocket expense for the prior year. 

Click The Link Above To Complete And Download An HRA Form.

Claimant Statement Form 

Contact PIBF With Questions In Regard To This Form.

 Pre-Existing Condition Form

Click The Above Link To Download a Pre-Existing Condition Form.

Reimbursement Agreement

Click The Above Link To Download a Reimbursement Agreement Form.

Release Of Medical Information Form 

Click The Above Link To Download a Release Of Medical Information Form.

Change Of Beneficiary For PIBF Death Benefit

Click The Link Above To Download A Change Of Beneficiary For PIBF Death Benefit Form.

To View, Print Or Edit The Forms On This Website, You Must Have Adobe Acrobat Reader Installed.   If you Do Not Then Click The Link Above To Download.