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.




Select your form:

Select your delivery method:


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