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Forms & Publications

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Catalog of Benefits
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Application Forms
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Price List
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Join the CCPOA

Member Benefits


ADB_PlanIcons
$5,000 Accidental Death Basic
Active
Summary Program Description
ADD_PlanIcons
Accidental Death & Dismemberment
Active
Application
Active
Brochure
Active
Plan Certificate 29312-0
Retired
Application
Retired
Plan Certificate 29313-0
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Basic Life
Active
Plan Certificate 29307-0
Retired
Plan Certificate 29308-0
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Disability Benefit Program: Gold Shield
Active
Gold Shield: Application
Active
Gold Shield: Brochure
CLOSED
Gold/Silver Shield: Compairison Chart
Closed to new enrollment
Active
Upgrade from Silver Shield
Active
Summary Program Description
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Legal Defense Fund
Active
Summary Program Description
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Medical Plan
Active
Evidence of Coverage (EOC)
Active
E-Z Summary
Retired
Medicare Supplement EOC
Retired
EZ Summary
Retired
Prescription Drug Plan EOC
Retired
Prescription Drug Plan Application
Retired
Prescription Drug Plan Summary-Formulary
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Piggyback
Active
Application
Active
Vision Claim Form
Retired
Application
Retired
Vision Claim Form
All Members
Piggyback Brochure
All Members
Summary Plan Description
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Primary Dental
Active
Brochure
Active
Plan Highlights
Active
Claim Form
Active
Dental Procedure Codes
Active
Summary Program Description
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Supplemental Term Life
Active
Brochure/Application
Active
New C/Os - Guarantee Issue
Active
Plan Certificate 29307-0
Retired
Brochure/Application
Retired
Plan Certificate 29308-0
Retired
Plan Certificate 29310-0
CLOSED
Senior Term Life Closed to new enrollment
Plan Certificate 29309-0
PB_PlanIcons
Triada Insurance
All Members
Triada Claim Form
All Members
Accident Defender: Flyer
All Members
Accident Defender: Plan Certificate
All Members
Shield Plus: Flyer
All Members
Shield Plus: Plan Certificate
Closed
LEGACY: Accident Champion Certificate
Closed
LEGACY: ADP Certificate
Closed
LEGACY: DAP Certificate
Closed
LEGACY: SDP Certificate
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U.S. Legal Services: Family Defender 
Active
Brochure
Retired
Application
All Members
Non-Network Claim Form
All Members
Privacy Form
All Members
Summary Program Description
PB_PlanIcons
VSP
Retired
Application
Retired
Brochure
All Members
Summary Program Description
PB_PlanIcons
Western Dental
Active
Summary Material Modifications
Active
Summary Program Description


Benefit Trust Forms & Docs

PB_PlanIcons
Benefit Trust Fund
All Members
Beneficiary Change Form
All Members
Change of Address Form
All Members
New York Life: Summary Program Description
Plan Details
Notice of Privacy Practices
Plan Details
Agreement & Declaration of Trust
Plan Details
Welfare Benefit Plan (Plan 501)
Plan Details
Disability Benefit Plan (Plan 502)
Plan Details
Supplemental Benefit Plan (Plan 503)
Plan Details
Summary Annual Report
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CCPOA Benefit Trust Fund
2515 Venture Oaks Way
Suite 200
Sacramento, CA 95833

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TWO TOWERS logo is a registered trademark of CCPOA Benefit Trust Fund