Law Enforcement Health Benefits Inc.

2233 Spring Garden Street 19130 | Philadelphia Pennsylvania | 215-763-8290

John J. Gaittens, Administrator
Ray Convery, Assistant Administrator



Forms Library

Below is a list of LEHB's most commonly requested forms. You may print out a blank form from it's link on this page, or you may request a blank form be emailed to you. Or you may request that a form pre-filled out form be mailed to your address of record on file with LEHB. LEHB takes your privacy seriously. For that reason, pre-filled forms cannot be emailed. Pre-filled forms will only be mailed via first class mail to the member's address on record with LEHB. Please make your selection below and click the "submit" button.

Name:

Payroll:

Email:

Select your form:

Select your delivery method:

or

Click on the links below and download the form

 Add or remove a dependent form

 How to add or remove dependents

 Change of address form

 Vision Claim Form