*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
10: Health Reimbursement Arrangement – HRA
11: Death Benefit Beneficiary Form
12: Claimant Statement Form – Death Benefit
13: Release Of Medical Information Form
14: Sav-Rx Covid Reimbursement Form
15: Appointment of Authorized Representative Form (For Appeal Procedure)
16: Retiree Health Insurance Premium
Authorization Agreement For Automatic Deduction
17: Disability Form Explanation
18: Short Term Weekly Disability Form
19: Notice Regarding Disability Provision – Posting of Hours
20: HRA Authorization Agreement For Automatic Deposits
21: COBRA Payment Authorization Agreement For Automatic Deduction
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