Request Hard Copies

Please complete and submit the following form to request hard copies of The Benefits Trust claim and administrative forms.

Contact Information

First Name

Last Name

Email (required)


Contract/Policy #

Company Name

Available DocumentsQuantity

Enrollment Form Standard: BT-EF-A

Change of Record: BT-CR-A

Termination/Rehire: BT-TR-A

Declaration Appointing Trustee: BT-DAT-A

Overage Dependent Enrollment: BT-OAD-A

Medical & Drug Claim Standard: BT-MM-A

Dental Claim Standard: BT-DE-A

Accident & Sickness Claim: BT-AS-A

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