Extended Health Care Forms:

Drug Claim Form

Dental Claim Form

Vision Care Claim Form

Extended Health Benefits Claim Form

Short Term Disability:

Employer Statement

Member Statement

Attending Physician's Statement

Member Confirmation of Illness Form (Covid-19)

Direct Deposit

Attending Physician's Update

Long Term Disability:

Employer Statement

Member Statement

Initial Attending Physician's Statement

Life and AD&D forms:

Life Claim Form

AD&D Form

Life Conversion

Change/Information Forms:

MBC Direct Deposit Application

Pension Spouse & Beneficiary Change Form

Pension Plan Enrollment Form

Life Insurance Beneficiary Designation

Member Name Change

H & W Notice of Change Form

362 H & W Enrollment

Prairie H & W Enrollment


Enrollment Form

Spouse Beneficiary Designation

Voluntary Contributions Request