Benefit Trust Fund - Forms
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Catalog of Benefits - Descriptions of all Trust Offered plans
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Application Booklet - Applications for all Trust offered plans
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Price List - Prices for all Trust offered plans
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Join the CCPOA - Click here to get the application
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Documents & Forms
- Member Benefits
- Member Forms
- CalPERS
Select a Program:
$5,000 Accidental Death
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Active: AD Basic: Summary Program Description
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Accidental Death & Dismemberment
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Active: Application
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Active: Brochure
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Active: Plan Certificate 29312-0
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Retired: Application
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Retired: Plan Certificate 29313-0
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Basic Life
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Active: Plan Certificate 29307-0
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Retired: Plan Certificate 29308-0
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Combined Insurance
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Combined Insurance: Brochure
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Combined Insurance: Claim Form
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Disability Benefit Program (DBP)
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Gold Shield: Brochure
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Gold Shield: New Officer 50% Discount Application
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Gold Shield/Silver Shield: Comparison Chart
See Catalog of Benefits
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Gold Shield/Silver Shield: Application
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Upgrade from Silver Shield
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Cadet Basics Flyer
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DBP: Summary Program Description
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Dental
Primary Dental
Western Dental
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Primary Dental: Brochure
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Primary Dental: Claim Form
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Primary Dental: Plan Highlights
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Primary Dental: Procedure Codes
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Primary Dental: Summary Plan Description
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Western Dental: Summary Material Modification
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Western Dental: Summary Plan Description
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Legal Programs
Legal Defense Fund (LDF)
U.S. Legal Services
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LDF: Summary Plan Description
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U.S. Legal: Brochure
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U.S. Legal: Non-Network Claim Form
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U.S. Legal: Privacy Form
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U.S. Legal: MSA Financial Counseling
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Retired: U.S. Legal Application
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U.S. Legal: Summary Program Description
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CCPOA Medical Plan
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Active: 2019 E-Z Summary
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Active: 2019 Medical Plan-Evidence of Coverage
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Retired: 2019 E-Z Summary
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Retired: 2019 Medical Plan/Medicare-Evidence of Coverage
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Retired: 2018 Prescription Drug Plan
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Retired: Prescription Drug Plan Application
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Piggyback
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Active: Piggyback Application
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Active: Piggyback Vision Claim Form
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Retired: Piggyback Application
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Retired: Piggyback Vision Claim Form
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Piggyback: Brochure
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Piggyback: Summary Plan Description
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Supplemental Term Life
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Active: STL- Rate Sheet
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Active: STL- Active Brochure/Application
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Active: STL- Plan Certificate 29307-0
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Retired: STL- Rate Sheet
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Retired: STL-Retired Brochure/Application
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Retired: STL-Retired Rollover Plan Certificate 29310-0
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New Hires: STL-Gurantee Issue Brochure/Application
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Closed: Senior Term Life: Plan Certificate 29309-0
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VSP
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Retired: VSP Brochure
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Retired: VSP Application
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VSP Summary Plan Description
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Select a Form / Document:
Trust Forms
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Beneficiary Change Form
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Change of Address Form
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Trust Documents
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Benefit Trust Fund: Agreement & Declaration of Trust
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Benefit Trust Fund: Notice of Privacy Practices
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Benefit Trust Fund: 2017 Summary Annual Report
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Benefit Trust Fund: Summary Material Modification
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Benefit Trust Fund: Welfare Benefit Plan (Plan 501)
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Benefit Trust Fund: Disability Benefit Plan (Plan 502)
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Benefit Trust Fund: Supplemental Benefit Plan (Plan 503)
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New York Life Program: Summary Program Description
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Select a Publication
CalPERS Publications
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Special Power of Attorney Booklet
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Beneficiary Designation Form
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2019 Health Benefit Summary
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2018 Health Benefit Summary
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The Benefit Trust Fund is not responsible for the accuracy of CalPERS information.
Always check with CalPERS for the latest updates.