Listed below are brochures, applications and relevant forms for the PBT Group, Individual and Additional Life and Health Insurance Plans. For additional information or help with the application process, please call 1.800.621.0748 and one of our Customer Service Representatives will be happy to assist you.

Medical Insurance for Individuals and their families:

Individual Health Benefits Brochure


Insurance Individual Plan Charts:
PBT Preferred Provider Option (PPO)
PBT Preferred Choice Indemnity
PBT Health Savings Account (HSA)-Qualified High Deductible Plans
PBT Value Plans (PPO)
PBT Value Health Savings Account (HSA)-Qualified High Deductible Plans
PBT Major Medical High Deductible Plan
Individual/Family Census Form
Illinois Standard Health Application for Individual and Family Health Insurance Coverage
PBT Individual and Family Supplemental Application
PBT Individual Supplemental Application/Change of Coverage (for making additions and/or changes to existing coverage or if enrolling for the first time)


Medicare Supplement Insurance (For members and spouses turning 65 or older):
The Outline of Coverage - Cover Page
Plan A Outline of Coverage
Plan F Outline of Coverage- Cover Page
Your Guide to Physicians' Benefits Trust Medicare Supplement Insurance Portfolio of Plans
Medicare Supplement Plan Rates
Turning 65 MediCap Enrollment Form (for members and/or spouses Turning 65)
MediCap - Medicare Supplement Plans Application (for members and/or spouses over 65)


Term Life Insurance:
Term Life Brochure
Term Life Rates
Term Life Application


Income Protection Plan:
Long Term Personal and Business Overhead Expense Income Brochure
Long Term Personal and Business Overhead Expense Income Rates
Long Term Disability Application
Business Overhead Expense Application


Dental Protection Plan:
Dental Protection Plan Brochure
Dental Protection Plan Application


Accidental Death & Dismemberment:
Accidental Death and Dismemberment Brochure
Accidental Death and Dismemberment Application

Small Group Health Benefits Program (2 to 50 eligible employees):

Health Benefits Brochure


Insurance Plan Charts:

PBT Preferred Provider Option (PPO)
PBT Preferred Choice Indemnity
PBT Health Savings Account (HSA)-Qualified High Deductible Plans

Group Census Form
Employer Application and Agreement
Illinois Standard Health Employee Application for Small Employers
PBT Small Group Supplemental Application/Change of Coverage (for initial application, new employees/hires, and additions and/or changes to current coverage)


Dental Protection Plan:
Dental Protection Plan Brochure
Dental Protection Plan Application

Large Group Health Benefits Program (50+ eligible employees):

Health Benefits Brochure
Health History Questionnaire


Insurance Plan Charts:

PBT Preferred Provider Option (PPO)
PBT Preferred Choice Indemnity
PBT Health Savings Account (HSA)-Qualified High Deductible Plans

Group Census Form
Employer Application and Agreement
Supplement Employer Application and Agreement
Group Application/Change of Coverage (for initial application, new employees/hires, and additions and/or changes to current coverage). Please read and follow the instruction on Page 1. Complete only those sections that pertain to the action you wish to take.


Claim Forms:
Medical claim form
Dental claim form


Important Notices:

HSA Limits for Contributions