This section can be used as a resource for employees on an ICBA Benefit Service's Build Your Own plan. It provides information, claim forms and sign-up forms for employees and administrators of the plan. Remember, it’s our job to make your life easier so if you can’t find what you’re looking for, please contact us.

• Application Form (PDF 19KB)
• Dental Claim Form (PDF 46KB)
• Extended Health Care Benefit Claim Form (PDF 80KB)
• Group Enrollment for Change Form (PDF 33KB)
• Group Health Evidence (PDF 106KB)
• Pay-Direct Drug Claim Form (PDF 171KB)
• Pre-Authorized Debit (PAD) Plan Information Sheet(PDF 40KB)
• Sustaining Membership Application (PDF 23KB)

The employee benefits booklet provides information on all the coverage options possible for The Owner/Operator Plan. Please refer to your summary sheet for your specific coverage.

Employee Benefits Booklet (PDF 4MB)

Know someone that is in need of a benefit plan? Refer them to us and when they sign up for one of our plans receive a $100 gift certificate! Click here to download the form.

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