Contact Us

Ask general questions, request an identification card, or contact us for a quote for your company. Select an appropriate online form below and submit it to us, or feel free to call us at 800-332-1168.

All information provided here is secured by state-of-the-art encryption.

Office Hours

Monday - Thursday: 7:30am to 4:30pm MST
Friday: 7:30am to 4:00pm MST

Request a Quote

General Question

Member ID Card Request

Full Name: First, Last: (Required)
Employer: (Required)
Inquiry Type: (Required)
Member ID: (Required)
Phone:
Email: (Required)
Question:

Member Third Party Liability Information

Member Name: First, Last (Required)
Email (Required)
Member ID (Required)
Patient Name (Required)
Services Provided By (Required)
Date of Service:
Total Charge Amount:
Was Claim Due to Injury? (Required)

Yes

No
Injury/Illness Description:
First Date of Treatment: (Required)
Date of Injury: (Required)
How Did The Injury Happen: (Required)
Place of Injury: (Required)
Was Injury at Work: (Required)
Do You Expect Further Treatment: (Required)
Is This Causing Aggravation at Work: (Required)
Has Employer Been Notified: (Required)
Is Injury From Motor Vehicle Accident: (Required)
Was Vehicle Covered By Insurance: (Required)
Other Party Name:
Other Party Address:
Other Party Phone:
Claim Number:
Policy Number:
Was Accident Reported to Law Enforcement:
Name of Agency:
Agency Address:
Has Attorney Been Retained:
Home Phone:
Work Phone:
Electronic Signature: (Required)

Employer Supply Request

Group Name: (Required)

Branch Number: (Required)

Caller Name: (Required)

Email: (Required)

Enrollment/Change Cards Qty:

Enrollment Packets Qty:

Medical Claim Forms Qty:

Dental Claim Forms Qty:

Vision Claim Forms Qty:

COBRA Forms Qty:

Rx Mail Order Forms Qty:

PPO Directories Qty:

SDA LDT/SDT Claim Forms Qty:

SDA LDT/SDT Certs Qty:

Standard Voluntary Life Booklets:

Other:

Website Accessibility Policy

CEBT Benefit by Trust is fully committed to providing accessible facilities, elements and channels of communication to all members of the public. As part of this commitment, CEBT Benefit by Trust has a policy of providing an accessible website compatible with the Web Content Accessibility Guidelines (WCAG 2.1) and commercial screen reading software. All features of the website are coded to allow individuals with vision and other impairments to understand and use the website to the same degree as someone without disabilities. We welcome feedback and can often resolve issues in a timely manner if they arise.

If you need any special assistance or accommodations:

Call us at (800) 332-1168

Ongoing Compliance Information

Compliance Officer

CEBT Benefit by Trust has designated a compliance officer for website disability-related accommodations. The compliance officer has received training in website accessibility and updates the site in accordance with those best practices. Contact our accessibility officer to report an issue.

Compliance Procedures and Reports

In addition to testing with users with a wide range of disabilities and coding our website to WCAG standards, CEBT Benefit by Trust regularly scans its website to ensure ongoing compliance, and makes timely changes to any inaccessible changes, if any are found.

Linked Documents and Third Parties

Please note that this site may link out to third-party websites, such as state or federal agencies, that do not have accessible content. This site may also include documents provided by third parties included in our agenda packets, for example. While we cannot control the accessibility of content provided by third parties, we are happy to assist any member of the public with reading and accessing content on our site.

See an opportunity for us to improve? Please contact our accessibility officer or call us at (800) 332-1168.

Report a Website Accessibility Issue

We are committed to your ability to access all content, and we will respond to all requests as soon as possible.