Benefit Trust Fund - Forms
|
Catalog of Benefits - Descriptions of all Trust Offered plans
|
|
Application Booklet - Applications for all Trust offered plans
|
|
Price List - Prices for all Trust offered plans
|
|
Join the CCPOA -
Click here to get the application
|
Documents & Forms
- Member Benefits
- Trust Publications
- CalPERS
Select a Program:
$5,000 Accidental Death
|
Active: AD Basic: Summary Program Description
|
Accidental Death & Dismemberment
|
Active: Application
|
|
Active: Brochure
|
|
Active: Plan Certificate 29312-0
|
|
Retired: Application
|
|
Retired: Plan Certificate 29313-0
|
Basic Life
|
Active: Plan Certificate 29307-0
|
|
Retired: Plan Certificate 29308-0
|
Disability Benefit Program (DBP)
|
Gold Shield: Brochure
|
|
Gold Shield/Silver Shield: Comparison Chart
See Catalog of Benefits
|
|
Gold Shield/Silver Shield: Application
|
|
Upgrade from Silver Shield
|
|
Cadet Basics Flyer
|
|
DBP: Summary Program Description
|
Dental
Primary Dental
Western Dental
|
Primary Dental: Brochure
|
|
Primary Dental: Claim Form
|
|
Primary Dental: Plan Highlights
|
|
Primary Dental: Procedure Codes
|
|
Primary Dental: Summary Plan Description
|
|
Western Dental: Summary Material Modification
|
|
Western Dental: Summary Plan Description
|
Legal Programs
Legal Defense Fund (LDF)
U.S. Legal Services
|
LDF: Summary Plan Description
|
|
U.S. Legal: Brochure
|
|
U.S. Legal: Non-Network Claim Form
|
|
U.S. Legal: Privacy Form
|
|
Retired: U.S. Legal Application
|
|
U.S. Legal: Summary Program Description
|
CCPOA Medical Plan
|
Active: 2021 Evidence of Coverage
|
|
Active: 2021 E-Z Summary
|
|
Retired: 2021 Medicare Suppliment EOC
|
|
Retired: 2021 E-Z Summary
|
|
Retired: 2021 Prescription Drug Plan EOC
|
|
Retired: 2021 Prescription Drug Plan Application
|
|
Retired: 2021 Prescription Drug Plan Summary/Formulary
|
Piggyback
|
Active: Piggyback Application
|
|
Active: Piggyback Vision Claim Form
|
|
Retired: Piggyback Application
|
|
Retired: Piggyback Vision Claim Form
|
|
Piggyback: Brochure
|
|
Piggyback: Summary Plan Description
|
Supplemental Term Life
|
Active: STL- Rate Sheet
|
|
Active: STL- Active Brochure/Application
|
|
Active: STL- Plan Certificate 29307-0
|
|
Retired: STL- Rate Sheet
|
|
Retired: STL-Retired Brochure/Application
|
|
Retired: STL-Retired Rollover Plan Certificate 29310-0
|
|
New Hires: STL-Gurantee Issue Brochure/Application
|
|
Closed: Senior Term Life: Plan Certificate 29309-0
|
Triada Insurance
|
Triada Claim Form
|
|
Accident Defender Flyer
|
|
Accident Defender Certificate
|
|
Shield Plus Flyer
|
|
Shield Plus Certificate
|
|
Legacy-Accident Champion Certificate
|
|
Legacy-ADP Certificate
|
|
Legacy-DAP Certificate
|
|
Legacy-SDP Certificate
|
VSP
|
Retired: VSP Brochure
|
|
Retired: VSP Application
|
|
VSP Summary Plan Description
|
Select a Form / Document:
Trust Forms
|
Beneficiary Change Form
|
|
Change of Address Form
|
Trust Documents
|
Benefit Trust Fund: Agreement & Declaration of Trust
|
|
Benefit Trust Fund: Notice of Privacy Practices
|
|
Benefit Trust Fund: 2018 Summary Annual Report
|
|
Benefit Trust Fund: Summary Material Modification
|
|
Benefit Trust Fund: Welfare Benefit Plan (Plan 501)
|
|
Benefit Trust Fund: Disability Benefit Plan (Plan 502)
|
|
Benefit Trust Fund: Supplemental Benefit Plan (Plan 503)
|
|
New York Life Program: Summary Program Description
|
Select a Publication
CalPERS Publications
|
Special Power of Attorney Booklet
|
|
Beneficiary Designation Form
|
The Benefit Trust Fund is not responsible for the accuracy of CalPERS information.
Always check with CalPERS for the latest updates.