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Application Form for our Individual Health & Dental Plans
We are pleased to provide an application form for our Individual Health & Dental Plans.
For your convenience, there is also a worksheet showing you all of our different plan options and their rates to help you choose.
Refer to your plan text for details and explanations of terms.
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About using forms in Acrobat
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- Due to a limitation with the free version of Acrobat Reader, you will not be able to save the information on this form that you enter using your computer. You will only be able to print the the information and return it to PBC. If you would like to be able to save the data entered into the form, you will need to purchase an upgrade to either Acrobat Approval or the full Acrobat product. These upgrades are available on the Adobe web site.
- To print this form, click on the print icon in the Acrobat toolbar.
- If you require further assistance, please see our Acrobat Help Page.
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