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Employee Benefits Forms

Home / Services & Products / Insurance Services / Insurance Forms / Employee Benefits Forms

If a school district has a need, chances are that PSBA has a service, expert or program to meet that need.

Disability Income Protection

  • Proposal Information
  • Long-Term Disability Enrollment Form (PSBA Form, Employee Benefits PDF)
  • Long-Term Disability Premium Statement
  • Short-Term Disability Premium Statement
  • Long-Term Disability Claim Form
  • Short Term Disability Claim Form
  • Notice of Conversion Form
  • Conversion Form
  • Participation Agreement

Group Life Insurance

  • Proposal Information
  • Beneficiary Form
  • Supplemental Life Enrollment Application
  • Extended Employee Application
    • Medical Underwriting: HIPAA Release Authorization
  • Notice of Conversion Privilege Form
  • Conversion Form
  • Claim Statement
  • Disability Claim - Waiver of Premium
  • Accidental Dismemberment Claim Form
  • Accelerated Benefit Claim Statement
  • Group Life Premium Statement
  • Long-Term Disability Enrollment Form
  • Surviving Family Claim Statement
  • Supplemental Life Premium Statement
  • Supplemental Life Premium Statement - Age Classifications

Opti-Vision Discount Vision Program

  • Request a Proposal e-mail

Section 125/TABS/Flexible Benefit Plans

  • Proposal Information
  • Participation Agreement

Self-Funded Dental & Vision

  • Proposal Form Go to SCS Website
  • School Claims Service: Dental & Vision Forms Go to SCS Website
  • SCS Online Forms Administration (login required) Claims Administration Online

Volunteer Risk Management Program

  • Claim Form (Excel spreadsheet) spreadsheet
 
          
    Insurance Fraud Hotline
    PSBA Insurance Trust

 

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PSBA Insurance Trust, PO Box 2042 | Mechanicsburg, PA 17055 | Phone (717) 506-2450 | Fax (717) 506-2470

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