REQUEST WEB SITE ACCOUNT
If you are an active
policyholder
of a group that has web site access with Physicians' Benefits Trust you can submit this form to request a web site account. The information you enter on this form must exactly match the account information in our system. Your group number is located in the upper right corner of your ID card.
Click here
to return to the PBT default web page.
All fields are required.
First Name
Last Name
Group Number
Social Sec Num or UID
(no dashes)
Date of Birth
(mm/dd/yyyy)
Email Address
Confirm Email Address