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

Email Address
Confirm Email Address