Health Benefits for Workers with Disabilities 1-800-226-0768 TTY 1-866-675-8440 Health Benefits for Workers With Disabilities  
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Health Benefits for Workers with Disabilities (HBWD) Application

Application Download


English HBWD Application (pdf)

Solicitud de HBWD en español (pdf)

Application Request

HBWD Application Request

Pedir por solicitudde HBWD

For more information or to request an application to be mailed, please call our hotline Toll-Free at:

The HBWD Application is available for download in Portable Document Format (PDF). You will need Adobe Acrobat Reader® to view or print these files.

If Acrobat Reader is not already installed on your computer, click on the icon below for a free Download. Then follow the instructions to install the program.

1-800-226-0768
TTY: 1-866-675-8440

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