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

The Pipeline Industry Benefit Fund must comply with pre-existing health care regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  If you have just become covered under the PIBF health insurance program and have a pre-existing condition, the pre-existing condition will not be covered until 12 months after the enrollment date.  

For pre-existing conditions, the enrollment date is the first day you earned hours toward establishing your initial eligibility or if the patient is a new dependent spouse (or child of a new spouse) the starting date would be the date of marriage.  To waive all or part of this 12-month exclusionary period, you must provide a document showing creditable coverage from your previous health care provider.  PIBF will eliminate one day's exclusion for each day of creditable coverage provided 63 days have not lapsed between the PIBF starting date and the last day of the creditable coverage

 Please advise if you or any of your dependents have been treated for any medical conditions during the six months prior to the enrollment date.  You may answer these questions on the form below.

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.