The Pension Boards - PBUCC - Life & Disability Forms

Life & Disability Forms

We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application. If you are enrolling in Life Insurance and Disability Income benefits you must also complete the Life Insurance and Disability Income (LIDI) Metlife Enrollment Change form.

Domestic Partnership Statement of Financial Interdependence Form

Life Insurance (LIDI) Designation of Beneficiary Form

Life Insurance and Disability Income (LIDI) Benefit Plan Enrollment Application

Life Insurance and Disability Income (LIDI) MetLife Enrollment Change Form

Optional & Additional Life Insurance Forms

Optional Additional Death Benefit Designation of Beneficiary Form

Statement of Dependent Eligibility Beyond Limiting Age in Plan Due to Mental or Physical Handicap

Statement of Health Form