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The
following forms are for the use of fully-insured group
members based in West Virginia.
-
If your group is based in Indiana,
click here.
-
If your group is based in
Michigan, click
here.
-
If your group is based in
Ohio, 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.
MedBen
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.
Acceptance
or Waiver of Coverage for Temporomandibular Disorders and Craniomandibular
Disorders
Employers can include this document
with their completed employer application to indicate acceptance or waiver of
this coverage. (This is not an employee selection form.)
MedBen
Employee Application (8½”x14”)
New and existing employees of a group
insured by MedBen should use this form to apply for health coverage for
themselves and their dependent(s).
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)
Please contact MedBen Customer Service (800-868-8425
or
medben@medben.com) to obtain a death claim form. 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.
MedBen
Mutual Forms • MedBen
Administrators Forms
MedBen
Specialty Services Forms • MedBen
Dental and VisionPlus Forms |
