Forms - PEBT

Forms are available here for your ease, or contact your District Benefits Administrator for copies

Administrative Forms

PEBT Benefits Enrolment Form
PEBT Benefits Change Form
Waiver of Coverage Form
Common Law Spouse Declaration Form (1 year)
Common Law Spouse Declaration Form (2 years)
Notice of Leave Form
Notification of Conversion Form
Contingent Beneficiary Form
Core LTD Enhancement Memo Template to Disabled Member – Administrative Use Only
Core LTD Enhancement Reinstatement Template Memo – Administrative Use Only
Mass Salary Upload Instructions – Administrator Use Only
Mass Salary Upload Template – Administrator Use Only

Carrier Forms

Medical Monitoring Reimbursement Claim

Medical Monitoring Reimbursement Claim Form

Life Claims

PBC Life Claim Form

AD&D Claims

To make a claim under Accidental Death & Dismemberment (AD & D), you will need to connect to AIG directly. Before contacting them, have the following information ready:

Name of Policyholder: Public Education Benefits Trust
Policy Number
Employer’s name and address
Member’s name and address
Member’s date of birth
Member’s date of employment
Member’s effective date of coverage
Member’s amount of insurance
Date of accident or death

For AD&D claims please contact 1-877-317-8060 or email ahclaimscan@aig.com.

Conversion to an Individual Plan

If you are retiring or leaving the District as an employee you may wish to seek coverage through an individual plan. Ensuring there is no lapse in your coverage can be beneficial. For move information about conversion options you can contact each of the Benefit Providers on the Notice of Conversion form provided to you by your District Benefits Administrator. The form will outline which benefits you are eligible to convert and the time limits for converting each benefit.

If you are eligible for Life conversion, please contact PBC for a conversion application form.

For AD&D conversion information, please contact:
AIG Insurance Company of Canada.

Please complete the conversion forms if you are eligible for extended health and dental coverage conversion.