<%@LANGUAGE="JAVASCRIPT" CODEPAGE="65001"%> Preferred Benefits Services Agency Inc.



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Our website serves as a one-stop site for many carrier forms for a variety of insurance coverages including enrollment forms and claim forms for medical, prescription drugs, dental, vision, short-term disability, long-term disability, and life. 

For any forms that we've missed, you may also visit our links under companies represented, which will send you directly to specific carrier websites.If you still can't find the form you are looking for, feel free to email us with your request.

*Note: Most of our forms can be downloaded to Adobe Acrobat. If you don't have Adobe Acrobat, click the Adobe link to
download. Acrobat Icon Link


Ameritas 

Dental & Vision Enrollment Form

Dental Enrollment Form

Vision Enrollment Form

Dental Claim Form

Vision Claim Form

Ameritas Logo

Anthem 

Medical Enrollment Form- Groups with 2-50 Employees

Medical Enrollment Form- Groups with 51+ Employees

Enrollment Change Form- Groups with 2-50 Employees

Enrollment Change Form- Groups with 51+ Employees

Termination Form- Groups with 2-50 Employees

Medical Claim Form

Rx Claim Form

Rx Mail Order Form

Transmittal Form

Life Beneficiary Form

Life Claim Form

Electronic Funds Transfer Set-up Form

Anthem Logo

Assurant 

Enrollment Form - All Types of Coverage

Life Beneficiary Form

Life Conversion Form

Life Claim Form

Long-Term Disability Claim Form

Short-Term Disability Claim Form

Assurant Logo

AUL/One America

Beneficiary Change Form

Disability Claim Form

Life Claim Form

One America Logo

Delta Dental 

Dental Enrollment Form

Dental Claim Form

Delta Dental

Fort Dearborn 

Life Enrollment Form

Beneficiary Change Form

Life Claim Form

Fort Dearborn Logo

Guardian

Beneficiary Change Form

Enrollment Form - All Types of Coverage

Evidence of Insurability

Dental Enrollment Form

Dental Claim Form

Life Insurance Claim Form

Long-Term Disability Claim Form

Short-Term Disability Claim Form

Guardian Logo

Humana

Enrollment Form- Groups with 2-50 Employees

Enrollment Form- Groups with 51-99 Employees

Enrollment Form- Groups with 100+ Employees

Life Beneficiary Change Form

Employee Change Form

Enrollment Change Form- Dental, Life, Vision

Rx Mail Order Form

Humana Logo

Lincoln Financial

Enrollment Form - All Types of Coverage

Adjustment Form

Change Form

Beneficiary Form

Evidence of Insurability Form

Life Insurance Claim Form

Life Insurance Conversion Form

Long-Term Disability Claim Form

Short-Term Disability Claim Form

Lincoln Financial Group Logo

MedBen

Medical Enrollment Form- Groups with 1-49 Employees

Medical Enrollment Form- Groups with 50+ Employees

Medical Claim Form

Rx Reimbursement Form

Rx Mail Order Form

MedBen Logo

Medical Mutual 

Enrollment Form- Groups with 1-19 employees

Enrollment Form- Groups with 20+ employees

SuperMed One Change Form

Medical Claim Form

Rx Claim Form

Rx Mail Order Form

Student Certification Form

Medical Mutual Logo

MetLife

Enrollment Form- All Types of Coverage

Dental ID Card

Dental Claim Form

Dental Enrollment Form

Life Claim Form

Life Beneficiary Form

Long-Term Disability Claim Form - Employee

Long-Term Disability Claim Form - Employer

Short-Term Disability Claim Form

Attending Physician's Statement

MetLife Logo

Principal

Enrollment Form - All Types of Coverage

Life Claim Form

Beneficiary Change Form

Employee Change Form

Principal Logo

Prudential 

Enrollment Form - All Types of Coverage

Life Claim Form

Short-Term & Long-Term Disability Claim Form

Prudential Logo

United HealthCare 

Enrollment Form- Groups with 2-9 Employees

Enrollment Form- Groups with 10-50 Employees

Enrollment Form- Groups with 51-99 Employees

Enrollment Form- Groups with 100+ Employees

Medical Claim Form

Life Beneficiary Form

Short-Term Disability Claim Form

Long-Term Disability Claim Form

Dental Claim Form

Rx Reimbursement Form

Rx Mail Order Form

Plan Administrator Change Form

United HealthCare Logo

VSP

Individual Enrollment Form

Claim Form

VSP Logo
© Copyright, 2010 Preferred Benefits Services Agency Inc.

611 South Sandusky Street │PO Box 868 │Delaware, Ohio 43015-0868 │800-558-5658
info@pbsai.com