The following forms are for the use of fully-insured group members based in Indiana.

• If your group is based in Michigan, click here.

• If your group is based in Ohio, click here.

• If your group is based in West Virginia, click here.

All forms are saved in the .PDF format. To view and print a form requires Adobe Acrobat Reader. You can download a free copy of Reader by clicking here.

If you have any questions about what forms your group uses, contact the MedBen Customer Service Department at 800-686-8425 or medben@medben.com. For technical questions relating to downloading and printing of forms, e-mail this site's webmaster at chuckj@medben.com.

All forms measure 8½”x11” unless otherwise indicated.
Forms open in a new browser window.

MedBen Mutual Claim Form
Use this form to submit a claim for incurred medical or hospital expenses.

Dental Claim Form
Use this form to submit a claim for incurred expenses covered under a MedBen Dental plan.

Disability Claim Form
Use this form to submit a claim for long-term or short-term disability benefits.

MedBen Employer Application
Employers should use this form to apply for group health insurance coverage under a MedBen-sponsored plan.

MedBen Employee Applications
New and existing employees of a group insured by MedBen should use one of the forms below to apply for health coverage for themselves and their dependent(s). (If you are not certain of the number of covered lives in your group, use the "Less Than 50 Covered Lives" form or ask your plan representative.)
Less Than 50 Covered Lives Enrolling
Large Group (50+ Covered Lives)

MedBen Change Request Form (8½”x14”)
Use this form to add/remove a spouse or other dependent(s) to/from employee coverage, or notify MedBen of a change in name, address, or marital status.

MedBen Dental Employee Application
New and existing employees of a group covered under MedBen Dental should use this form to apply for dental coverage for themselves and their dependent(s). This form is also used to make changes (name, address) to personal information and add/delete dependents to/from MedBen Dental coverage.
(NOTE: If your group also has group health coverage under a MedBen Mutual-sponsored plan, apply for MedBen Dental coverage using a MedBen Employee Application [8½”x14”], and a MedBen Dental and VisionPlus Change Request Form [8½”x14”] to make changes to dental coverage.)

MedBen VisionPlus Employee Application
New and existing employees of a group covered under MedBen VisionPlus should use this form to apply for vision coverage for themselves and their dependent(s). This form is also used to make changes (name, address) to personal information and add/delete dependents to/from MedBen VisionPlus coverage.
(NOTE: If your group also has group health coverage under a MedBen Mutual-sponsored plan, apply for MedBen VisionPlus coverage using a MedBen Employee Application [8½”x14”], and a MedBen Dental and VisionPlus Change Request Form [8½”x14”] to make changes to vision coverage.)

MedBen Dental and VisionPlus Employee Application
New and existing employees of a group covered under MedBen Dental and/or VisionPlus should use this form to apply for dental/vision coverage for themselves and their dependent(s). This form is also used to make changes (name, address) to personal information and add/delete dependents to/from MedBen Dental and/or VisionPlus coverage.
(NOTE: If your group also has group health coverage under a MedBen Mutual-sponsored plan, apply for MedBen Dental and/or VisionPlus coverage using a MedBen Employee Application [8½”x14”], and a MedBen Dental and VisionPlus Change Request Form [8½”x14”] to make changes to dental and/or vision coverage.)

Prescription Drug Reimbursement Form
Employees with MedBen prescription drug coverage should use this form to request reimbursement for a prescription drug claim.

Prescription Drug Mail Order Form
Employees with MedBen prescription drug coverage should use this form to purchase mail-order prescription drugs.

Death Claim Form (Life Insurance Claim) 
Employers must complete and return this form (accompanied by a certified copy of the death certificate) in order for designated beneficiary to receive life insurance benefits.

Notice of Appeal/Designation of Authorization Form
Employees wishing to file an formal appeal of a disputed claim should use this form.  They can also designate another entity to file an appeal on their behalf.

MedBen Mutual Forms • MedBen Administrators Forms
MedBen Specialty Services Forms • MedBen Dental and VisionPlus Forms