active & retired forms - ccpoabtf.org

ApplicationsActive & Retired Forms

www.ccpoabtf.orgCCPOA Benefit Trust Fund

A guide to benefits offered by the CCPOA Benefit Trust Fund to CCPOA members and their families.

rank & file supervisor retired

A:3

rank & file

Active CCPOA Application A:5

Accidental Death & Dismemberment A:7

Disability Benefit Plan A:9

Piggyback A:11

Supplemental Term Life A-13 – A:16

Beneficiary Change Form A:17

retired

Retired CCPOA Application A-21

Retired Piggyback A:23

Retired Legal: Family Defender A:25

Retired Vision A:27

Retired Accidental Death & Dismemberment A:29

Retired Supplemental Term Life A:31 – A34

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You can download more information on all our programs including complete plan documents from our website:

www.ccpoabtf.org

BTF Program Availability


$5,000 Accidental Death • •

Basic Life Insurance (No Application Required) • • •

U.S. Legal • • •

Dental • •

Vision • • •

CCPOA Medical Plan • • •

Accidental Death & Dismemberment • • •

Triada Insurance • • •

Disability Benefit Plan • •

Legal Defense Fund (No Application Required)

• •

Piggyback • • •

Supplemental Term Life • • •

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IMPORTANT: You must be a member of the CCPOA or the CCPOA Retired Chapter to take advantage of the voluntary programs in this catalog.

It’s not too late! CCPOA Union applications online: ccpoa.org

If you have any questions regarding CCPOA membership please contact the Union directly at: CCPOA 755 Riverpoint Drive West Sacramento, CA 95605-1634 800-821-6443

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NOTICE: Pursuant to Bylaws Article II, Section 4, in order to be eligible as a retired member and receive the benefits of such membership, one must be an uninterrupted member in good standing, except for leaves of absence, from July 1, 2018 until the date their retirement becomes effective or sixty (60) consecutive months prior to their retirement (whichever is shorter).

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

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YOU CAN NOW SIGN-UP ONLINE DIRECTLY AT CCPOA

GO TO: CCPOA.ORGCONTACT CCPOA BY PHONE:

SACRAMENTO OFFICE FRESNO OFFICE RANCHO CUCAMONGA OFFICE

1-800-821-6443 1-800-832-1415 1-800-221-7397

Mailing Address: CCPOA 755 Riverpoint Drive | West Sacramento, CA 95605-1634

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Not a member of the California Correctional Peace Officers Association?

Application CCPOA Active

Remember - You must be a member of CCPOA to enroll in programs offered by the Benefit Trust Fund. IF YOU HAVE ANY QUESTIONS REGARDING OTHER BENEFITS AVAILABLE TO ACTIVE MEMBERS, PLEASE CONTACT THE TRUST.

MEMBERSHIP APPLICATION

CALIFORNIA CORRECTIONAL PEACE OFFICERS ASSOCIATION

Member Effective Date:

CCPOA USE ONLY

Job Title ChangeRecycle & Date Recycled

I hereby make application for membership in California Correctional Peace Of cers Association (CCPOA), and authorize a membership dues deductionfrom my salary, in accordance with regulations of the California State Controller, and designate the CCPOA as my sole and exclusive representative forthe purpose of negotiating with my employer on my behalf on all matters affecting my employment relations, including, but not limited to, wages, hours,and other terms and conditions of my employment. As condition of membership in CCPOA, I agree to abide by the constitution and By-Laws ofCCPOA, and faithfully to carry out my obligations under same. Dues for all job classes are 1.3% of top step CO salary. Your dues include a subscription to the Peacekeeper magazine.

Rev 4/19

RECEIVED BY CCPOA:

Clearly Print Name:

SSN#

HOME ADDRESS:

STATE

HOME PHONE NO.:

EMPLOYED AT (Facility):

JOB TITLE:

COLLECTIVE BARGAINING STATUS:

BENEFICIARY’S NAME:

Signed:

(Relationship)

Date:

Rank and File Excluded from bargaining

Academy Only (Start of Class/Date):

CCPOA CHAPTER:

BIRTHDATE:

ZIP CODE:

E-MAIL:

APT#:

CITY/TOWN:

Are you a permanent intermittent employee (PIE)? Yes No

First M.I. Last

( )

( ) Phone:

CELL PHONE NO.: ( )

This authorization will remain in effect until cancelled by CCPOA at my written request subject to the provisions of any Memorandum of Understanding in effect between the State and CCPOA that applies to my classification. I understand that termination of membership will affect some or all of the benefits received from CCPOA and/or the CCPOA Benefit Trust Fund.

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CCPOA Benefit Trust Fund 2515 Venture Oaks Way, Suite 200

Sacramento, CA 95833-4235 www.ccpoabtf.org

1. Print-out this form. 2. Fill out application. 3. Sign and Date the form. 4. Mail your application to:

We’ve Got You Covered. 1-800-In-Unit-6

1-800-468-6486

Fold up and seal to return mail

Fold down and seal to return mail

AC T I V E

AD&D Application FormADD

Request for Group Insurance from: Group Accidental Death And Dismemberment Insurance Active

Underwritten by: New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010 Offered through CCPOA Benefit Trust Fund 1-800-468-6486

Mail completed form to:

CCPOA Benefit Trust Fund 2515 Venture Oaks Way, Suite 200 Sacramento, CA 95833-4235

I hereby apply for and authorize the necessary salary deductions for the premium to pay for Accidental Death and Dismemberment insurance under the terms of the Master Policy as follows:.

Full Name (print): Birthdate: SSN (Last 4):Sex: Male Female

Address: City: State: ZIP:

Phone: E-mail: Occupation or Position:

Beneficiary: Relationship: Beneficiary SSN: Beneficiary Occupation:

Beneficiary Address: Amount of Principal Sum: See Price List $

Monthly Premium: See Price List $

Dependent: Relationship: Date of Birth:Sex: Male Female

Dependent: Relationship Date of Birth:Sex: Male Female

■ Plan Selection (Check One)

Member Only Family Plan*

* Applicant will be Spouse’s and Dependent’s beneficiary

Amount of Insurance - Spouse and Children covered only if Family Plan is checked

■ Member 100% of Principal Sum

■ Spouse 60% of Principal Sum (if NO children)

50% of Principal Sum (if children)

■ Each Child 15% of Principal Sum (if spouse)

20% of Principal Sum (if NO spouse)

Is spouse an Active or Retired CCPOA Member? Check box: Yes or No Note: If you are covered as a member, you cannot be covered as a dependent of another member.

I hereby enroll in the Accidental Death and Dismemberment Program, underwritten by New York Life Insurance and o昀ered through the CCPOA Benefit Trust Fund. I have read and understand the conditions and exclusions of the program. I understand that my coverage will become e昀ective upon the first day of the month following the administrator’s receipt of this enrollment form and my first premium payment.

Fraud Notice – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

By signing and dating this application, I request the insurance indicated, understand the e昀ective date criteria, and attest to having read the Fraud Notice indicated above, and that to the best of my knowledge and belief, the answers to the questions are true and complete. I understand the principal sum automatically reduces based on the schedule in my Certificate of Insurance and that the premium is payroll deducted.

Signature of Applicant:

XDate of Application:

Policy Number: G-29312-0 GMA-GI 9/09ed

1. Fill out application. 2. Sign and Date the form. 3. Mail your application to:

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CCPOABenefitTrustFund2515VentureOaksWay,Suite200Sacramento,CA95833-9978

BUSINESSREPLYMAIL FIRST-CLASSMAILPERMITNO.149SACRAMENTO,CA

POSTAGEWILLBEPAIDBYADDRESSEE

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IFMAILEDINTHE

UNITEDSTATES

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1-800-468-6486



Disability Application FormDBP

Application CCPOA Disability Benefit Plan ActiveFull Name (print): Birthdate: SSN (Last 4): Sex:

Male FemaleAddress: City: State: ZIP:

Phone: Graduation Date (New Officer Only):IN THE PAST 5 YEARS has there existed, or have you been treated for or told by a physician or practitioner that you have conditions implicating any of the following:

YES NO YES NO

A. The brain, nervous system, epilepsy, Parkinson’s disease, stroke, mental or nervous disorder? F. The endocrine system including diabetes, thyroid or

adrenal disorders?

B. The respiratory system including tuberculosis, emphysema or COPD? G. Cancer, tumor, Hodgkin’s disease, leukemia, muscle dis-

orders including Muscular Dystrophy or Multiple Sclerosis?

C. The heart, heart attack, heart murmur, blood, anemia, high blood pressure, rheumatic fever or vascular disease?

H. Acquired Immune Deficiency Syndrome (AIDS), AIDS

Related Complex (ARC), HIV or any other immune deficiency disorder?

D. The gastrointestinal tracts, stomach, gall bladder, liver, hepatitis or pancreas disorders? I. Bone Disease or bone injuries including fractures?

E. The genito-urinary system, kidneys, reproductive organs including prostatitis or uterine fibroids? J. Any injury, disease, condition or abnormality not

mentioned above?

K. Are you actively working within the duties of your occupation?

E-mail:

Height: Weight:

Plan Selection at current monthly rate All Rates effective 07/01/2019

GOLD SHIELD $55.00/mo

“I hereby authorize the State Controller to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace O�cers Association (CCPOA). This authorization will remain in e昀ect until canceled by me or by CCPOA Benefit Trust Fund. I certify that I am a member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.” AC T I V EAUTHORIZATION: I understand that I will be required to sign a release of medical information provided to me by the Trust O�ce to determine eligibility for participation in and/or benefits under the Disability Benefit Plan. If my application for participation in the Disability Benefit Program is approved my signature serves as my express written authorization of payroll deductions for the coverage I have elected at the rate in force until I notify the Trust in writing to discontinue deductions, or otherwise cease to be eligible to participate.

Signature of Applicant: X

Date of Application:

■■ New Officer Special Offer $27.50/mo 1st year Gold ShieldDate of Graduation: (Must be within 90 days to qualify)

Please explain all of the “YES” answers checked, except “K” (including dates)

If necessary, use additional paper. The falsity or lack of completeness of any

statement made on this application shall be su�cient reason for the denial, suspension or

termination of benefits under this program.


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1-800-468-6486



Piggyback Application FormUSLPB

Application CCPOA Piggyback Program Active

CCPOA Benefit Trust Fund 1-800-468-6486Full Name (Print): Birthdate: SSN (Last 4):

Sex: Male Female

Address: List below names and birth dates of spouse and all dependent children under 26 years of age. (Birth dates are required)

First Middle Last Date of Birth Family RelationshipCity: State: ZIP:

E-mail:

Phone:

■ Plan Selection at current monthly rate (Check One) Active Member Only $14.00 Active Member and one or more dependents $26.00

I hereby authorize the State Controller to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace O�cers Association (CCPOA). This authorization will remain in e昀ect until cancelled by me or by CCPOA. I certify that I am a member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.



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G-29307-0 GMA-EZ2

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Request for Group Insurance from: New York Life Insurance Company

51 Madison Avenue, New York, NY, 10010


GROUP SUPPLEMENTAL TERM LIFE INSURANCE

Please complete and return this form to the Benefit Trust FundResidents of New York please call the Trust at 1-800-468-6486 for a NY specific application.

CCPOA Active Members STL

Please Print Use Dark Ink Do Not Erase Initial All Changes. Office Use:

Policyholder and Participating Organizations: CCPOA Benefit Trust Fund

Policy No. G29307 Height: Ft__________In_________ Weight: _________________lb

CCPOA Members Name (first, Middle Initial, Last) Date of Birth: Male Female

Street: Phone No.: Last 4 of SSN:

City: Email: State: Zip:

Proposed Insured’s Occupation and Facility:

Beneficiary – Print full name & relationship to you

Name (Primary): Relationship:

Beneficiary Address: Beneficiary SSN:

Name (Contingent): Relationship:


The Proposed Insured will be the beneficiary for any Dependent Coverage desired.

For CCPOA Member I hereby apply for a benefit amount of:

$____________________

($25,000 minimum up to $500,000 maximum in $25,000 increments. See rate chart.)

New Coverage Change in coverage

IF REQUEST IS TO CHANGE EXISTING COVERAGE, PRINT TOTAL AMOUNT DESIRED

For Office Use Only_________________________________________________

For CCPOA Member’s Spouse I hereby apply for a benefit amount of:

$____________________

($12,500 minimum up to $50,000 maximum in increments of $12,500. The spouse benefit amount must be no greater than 50 percent of the member’s coverage.)

Is spouse an Active or Retired CCPOA Member? Check box: Yes or No

Coverage for dependent child(ren). $750/$7,500 benefit



If Spouse/Dependent Coverage is desired, complete the following:

Full Name of Spouse/Dependent Children Relationship Birth Date Height Weight

Member Statement of Health:

To the best of your knowledge and belief, answer the following questions as they apply to you and all dependents to be insured: MEMBER SPOUSE

A Are you taking any prescribed medication or receiving or contemplating any medical attention or surgical treatment?YES

NO

YES

NO

B

During the past five years have you ever been medically diagnosed by a physician as having or been treated for: heart trouble, elevated blood pressure, gynecological or genitourinary disorders, ulcers, cancer, diabetes, mental or nervous disorder or psychotherapeutic treatment, epilepsy, respiratory disorder, kidney or liver disorder (including hepatitis), en-larged lymph nodes or immunodeficiency disorder, thyroid disorder, blood disorder, albumin, blood, pus, or sugar in urine, back trouble/disorder, arthritis, or unexplained weight loss?

C During the past five years have you been counseled, treated, or hospitalized for the use of alcohol or drugs?

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Depending on the amount of insurance you are requesting, you will be contacted by a service provider on behalf of New York Life Insurance Company to ask you about your medical history. What time and telephone number would be best to contact you? ________________________________________________________

Details (please fill out if answered “YES” to A, B, or C)

G-29307-0 GMA-EZ2

Please check “Yes” or “No” By applying for this insurance, do you intend to replace, discontinue, or change an existing policy of life insurance?

Member: YES NO

Spouse: YES NO

Do you have other life insurance in force? If “Yes” total amount in all companies:

Member: $_________________ Spouse: $___________________

Do you have other insurance applications pending? If “Yes” indicate amount and company.

Member: $_________________ Spouse: $___________________

Company: _________________ Company: __________________

FRAUD NOTICE – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. The falsity of any statement in the application for any policy shall not bar the right to recovery under the policy unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer.

AUTHORIZATION & SIGNATURE: I understand that New York Life Insurance Company has the right to require additional information and, if necessary, an examination by a physician. I ask New York Life to rely on all such statements made on this form, and any supplements to it, while considering this request. I also understand that the coverage afforded will be in consideration of the answers and statements set forth above.

AUTHORIZATION: I hereby authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medical or medically related facility, laboratory, insurance company, MIB, Inc. (“MIB”), or other organization, institution or person, that has any records or knowledge of me or my health to release information, including prescription drug records, maintained by physicians, pharmacy benefit managers, and other sources of information to New York Life Insurance Company, its reinsurers, its subsidiaries or the plan administrator about the physical and mental health of any persons proposed for insurance, including significant history, findings, diagnosis and treatment, but excluding psychotherapy notes for the purpose of evaluating my application for insurance. Health information obtained will not be re-disclosed without my authorization unless permitted by law, in which case it may not be protected under federal privacy rules. For example, New York Life may be required to provide it to insurance, regulatory, or other government agencies. In this case, the information may no longer be protected by the rules governing your AUTHORIZATION.

A photocopy of this AUTHORIZATION and request form shall be as valid as the original. In all circumstances, my authorized agent, representative, or I may request a copy of this AUTHORIZATION. This AUTHORIZATION shall be valid for a period of 24 months from the date signed, unless sooner revoked. The AUTHORIZATION may be revoked at any time by sending written notice to New York Life Insurance Company. My revocation will not be effective to the extent that New York Life or any other person already has disclosed or collected information or taken other action in reliance on it, or to the extent that New York Life has a legal right to contest a claim under an insurance certificate or the certificate itself.

By signing and dating this application, I member/spouse request the insurance indicated; and the member and any person proposed for insurance consent to authorize the disclosure of information to and from the providers noted above and in the IMPORTANT NOTICE enclosed, including making a brief report of [my/our] protected health information to MIB, Inc.; and attest to having read the IMPORTANT NOTICE enclosed and Fraud Notice indicated above, including how [my/our] information is exchanged with MIB, and that to the best of [my/our] knowledge and belief, the answers provided to the questions are true and complete.

I hereby authorize the State Controller to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace Officers Association (CCPOA). The authorization will remain in effect until cancelled by me or by CCPOA. I certify that I am a member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.

Member Signature Date

Spouse Signature (if enrolling) Date

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G-29307-0 GMA-GI 1/21ed




Note: If you are covered as a member, you cannot be covered as a dependent of another member.

Please complete and return this form to the Benefit Trust Fund


Guarantee Issue Plan

New Officers OnlySTL


Policyholder and Participating Organizations:

CCPOA Benefit Trust Fund

Policy No.

G29307Height: Ft______________In_____________

Weight: ______________________________lbCCPOA Members Name (First, Middle Initial, Last) Date of Birth:

Male Female









Guarantee Issue Supplemental Term Life – Indicate N/A if Dependent Coverage is not desired

Member Name: Male

Female

Date of Birth: Benefit Amount:

$125,000 Monthly Premium:

Spouse Name: Male

Female12,500

Children: Male

Female

15 days - 6 months of age $750

6 months or older $7,500

$1.65 per family/ per month

Male

Female



Male

Female



Male

Female



Male

Female



Hire Date:

Total Premium:


Member: YES NO

Spouse: YES NO


Member: $ _______________________________

Spouse: $ _______________________________


Member: $ _______________________________

Company: ________________________________

Spouse: $ _______________________________

Company: ________________________________

FRAUD NOTICE – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

I have read and understand the conditions and exclusions of this group term life insurance plan. I understand that my coverage will be effective the first day of the month immediately following the month for which a payroll deduction is received for the Supplemental Term Life premium, provided that I am actively at work and a CCPOA member on that date. I also understand that the coverage afforded will be guaranteed issue to me based on the statements I have set forth.

NAMING YOUR BENEFICIARY

It is important that your beneficiary designation be clear so that there will be no question as to your meaning. When naming your beneficiary(ies) please include their full name, address, relationship to you, and if a minor, the age of that minor. If the beneficiary is not related to you either by blood or marriage, insert the words “Not Related.” The beneficiary box is on the front of this form.

If you need assistance, contact the Trust at 1-800-In-Unit-6.

Following are examples of the most common designations:

Mary J. Doe, Wife. (not Mrs. John Doe) •

Mary J. Doe, Wife, if living, otherwise to Joe W. Doe, Son. •

Mary J. Doe, Wife, if living, otherwise to Jane Doe, Daughter, and Joe W. Doe, Son, in equal shares, or to the survivor. •

Estate of the Insured. •

If you name more than one beneficiary with unequal share, please show the amount of insurance to be paid to each •beneficiary in fractional parts. For example: “1/3 to Mary Jones, Mother, and 2/3 to Edith Jones, Wife”.

By signing and dating this application, I and my spouse/domestic partner (if proposed for insurance), request the insurance indicated, understand the effective date criteria, and attest to having read the Fraud Notice indicated above, and to the best of my knowledge and belief, the answers to the questions are true and complete. I understand the principal sum automatically reduces based on the schedule in my Certificate of Insurance and that the premium is payroll deducted.



G-29307-0 GMA-GI

1/21ed

Member Name Social Security Number (Last 4)

Address City State / ZIP

Institution Home / Cell Phone

CCPOA Member Information

Name - First Middle Last Birthdate: % Social Security Number (Last 4)

Home or Cell Phone Relationship to member

Address (Number and Street) City State Zip Code













Primary Beneficiary Name(s): If more than one beneficiary is listed the total percentage must equal 100%

Contingent Beneficiary Name(s): If more than one beneficiary is listed the total percentage must equal 100%.

Please check all boxes this change applies to:

ACTIVE MEMBERS RETIRED MEMBERS

Active Base Life Retired Base Life

Supplemental Term Life Retired Term Life

AD&D Retired AD&D

Accidental Death $5,000 Senior Term Life

Change of Beneficiary Request

__________________________________________________ _____________________ Signature Date

Mail to: CCPOA Benefit Trust Fund 2515 Venture Oaks Way, Suite 200 | Sacramento, CA 95833-4235 Phone: 800.468.6486 | 916.779.6300 | Fax: 916.779.6355

2020_BenChg_SelfMailier Q120P04

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NOPOSTAGENECESSARY

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Retired Applications

Retired CCPOA Members:

Your applications are in this section.


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Active CCPOA Members:

Your applications are in the front of the book.

YOU CAN NOW SIGN-UP ONLINE DIRECTLY AT CCPOA

GO TO: CCPOA.ORGCONTACT CCPOA BY PHONE:

SACRAMENTO OFFICE FRESNO OFFICE RANCHO CUCAMONGA OFFICE

1-800-821-6443 1-800-832-1415 1-800-221-7397

Mailing Address: CCPOA 755 Riverpoint Drive | West Sacramento, CA 95605-1634

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Not a member of the Retired Chapter of the California Correctional Peace Officers Association?

Application CCPOA Retired Chapter Retired

Remember - You must be a member of CCPOA to enroll in programs offered by the Benefit Trust Fund. IF YOU HAVE ANY QUESTIONS REGARDING OTHER BENEFITS AVAILABLE TO ACTIVE MEMBERS, PLEASE CONTACT THE TRUST.

RETIRED MEMBERSHIP APPLICATION

CALIFORNIA CORRECTIONAL PEACE OFFICERS ASSOCIATION

Member Effective Date:

CCPOA USE ONLY

his organization.RECEIVED BY CCPOA:

Print Name

Last Name M.I.First SSN#

Street Address

City

Apt#

State Zip

Home Phone Cell/Other Phone E-Mail

Birth Date Last Employed At Last CCPOA Chapter

Title CCPOA Member Since Retirement �ate

Relationship Phone Number

Signed Date

Pursuant to Bylaws Article II, Section 4, in order to be eligible as a retired member and receive the benefits of such membership, one must be an uninterrupted member in good standing, except for leaves of absence, from July 1, 2018 until the date their retirement becomes effective or sixty (60) consecutive months prior to their retirement (whichever is shorter).

hereby apply for membership in the California Correctional Peace Officers Association Retired Chapter, and authorize a monthly deduction of $20.00 from my retirement warrant received through the Public Employees Retirement System (PERS). The $20.00 deduction is payment for participation in he retiree life insurance policy and other retiree membership benefits which may be available.

hereby authorize the Public Employees Retirement System (PERS) to withhold from my Retirement Warrant, in accordance with the rules of said system, deduction for retiree benefits until such time as I file in this same office a written request for termination. I also authorize the Association to certify to PERS the amount of the deduction, and any subsequent changes to that amount. I understand PERS cannot process a termination notice received directly from me, and that excess deductions, taken in error will be refunded to me by the association and not PERS. This authorization will remain in effect until canceled by the Association at my written request. I understand termination of membership will cancel all deductions made under

PAYROLL DEDUCTION AUTHORIZATION/MEMBERSHIP APPLICATION

Beneficiary

Rev 0 /2

: : : :

: :

: : :

: : :

: : :

:::

: :

: : :

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1-800-468-6486



Piggyback Retired Application FormUSLPB

Application CCPOA Piggyback Program Retired


Sex: Male Female



E-mail:

Phone:

■ Plan Selection at current monthly rate (Check One) Retired Member Only $16.00 Retired Member and one or more dependents $32.00

I hereby authorize the CalPERS to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace O�cers Association (CCPOA). This authorization will remain in e昀ect until cancelled by me or by CCPOA. I certify that I am a member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.


XDate of Application:R E T I R E D


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1-800-468-6486



Family Defender Retired Application FormUSL

Application CCPOA Family Defender Program RetiredCCPOA Benefit Trust Fund 1-800-468-6486Full Name (print): Birthdate: SSN (Last 4):

Sex: Male Female

Address: City State: ZIP

Phone: E-mail:

■ Program Selection at current monthly rate (Check One)

The CCPOA Family Defender Program $13.99/mo Excludes Legal Defense Fund Benefits

I hereby authorize the CalPERS to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace O�cers Association (CCPOA). This authorization will remain in e昀ect until cancelled by me or by CCPOA. I certify that I am a retired member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.



R E T I R E D


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UNITEDSTATES


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1-800-468-6486



VSP Retired Application FormUSLVSP

Application CCPOA Vision Program Retired


Sex: Male Female



E-mail:

Phone:

■ Plan Selection at current monthly rate (Check One) STANDARD PLAN OR EXAM-PLUS PLAN Member Only $9.20 Member Only $1.98 Member + 1 Dependent $13.19 Member Plus One Dependent $2.72 Member + Family $23.54 Member Plus Family $4.65 I hereby authorize the CalPERS to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace O�cers Association (CCPOA). This authorization will remain in e昀ect until cancelled by me or by CCPOA. I certify that I am a member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.


XDate of Application:R E T I R E D


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UNITEDSTATES






1-800-468-6486



R E T I R E D

AD&D Retired Application FormADD

Request for Group Insurance from: Group Accidental Death And Dismemberment Insurance Retired

Underwritten by: New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010 Offered through CCPOA Benefit Trust Fund 1-800-468-6486

Mail completed form to:


I hereby apply for and authorize CalPERS to deduct from my retirement benefit the necessary deductions for the premium to pay for Accidental Death and Dismemberment insurance under the terms of the Master Policy as follows. I understand that there are benefit reductions at attainment of certain ages. (See the brochure for more information.)

Full Name (print): Birthdate: SSN (Last 4):Sex: Male Female

Address: City: State: ZIP:

Phone: E-mail:

Beneficiary: Relationship: Beneficiary SSN:

Beneficiary Address: Amount of Principal Sum: See Price List $

Monthly Premium: See Price List $

Dependent: Relationship: Date of Birth:Sex: Male Female

Dependent: Relationship Date of Birth:Sex: Male Female

■ Plan Selection (Check One)

Member Only Family Plan*

* Applicant will be Spouse’s and Dependent’s beneficiary

Amount of Insurance - Spouse and Children covered only if Family Plan is checked■ Member 100% of Principal Sum

■ Spouse 50% of Principal Sum (if NO children)

40% of Principal Sum (if children)

■ Each Child 10% of Principal Sum (if spouse)

15% of Principal Sum (if NO spouse)

Is spouse an Active or Retired CCPOA Member? Check box: Yes or No Note: If you are covered as a member, you cannot be covered as a dependent of another member.

I hereby enroll in the Accidental Death and Dismemberment Program, underwritten by New York Life Insurance and o昀ered through the CCPOA Benefit Trust Fund. I have read and understand the conditions and exclusions of the program. I understand that my coverage will become e昀ective upon the first day of the month following the administrator’s receipt of this enrollment form and my first premium payment.

Fraud Notice – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.

By signing and dating this application, I request the insurance indicated, understand the e昀ective date criteria, and attest to having read the Fraud Notice indicated above, and that to the best of my knowledge and belief, the answers to the questions are true and complete. I understand the principal sum automatically reduces based on the schedule in my Certificate of Insurance and that the premium is payroll deducted.



Policy Number: G-29313-0 GMA-GI 9/09ed


A:30





UNITEDSTATES


G-29310-0 GMA-EZ2 1/21 ed

Continued on next page




GROUP SUPPLEMENTAL TERM LIFE INSURANCE CCPOA Retired Members

Please complete and return this form to the Benefit Trust Fund

ALREADY RETIRED – USE THIS FORMSTL


Policyholder and Participating Organizations:

CCPOA Benefit Trust FundPolicy No.

G29310 Height: Ft__________In_________ Weight: _________________lb

CCPOA Members Name (first, Middle Initial, Last) Date of Birth: Male Female










For Retired CCPOA Member I hereby apply for a benefit amount of:

$____________________

($25,000 minimum up to $250,000 maximum in $25,000 increments. See rate chart.)

New Coverage Change in coverage



For Retired CCPOA Member’s Spouse I hereby apply for a benefit amount of:

$____________________

($12,500 minimum up to $50,000 maximum in increments of $12,500. The spouse benefit amount must be no greater than 50% of the member’s coverage.)





If Spouse/Dependent Coverage is desired, complete the following:


Member Statement of Health:

To the best of your knowledge and belief, answer the following questions as they apply to you and all dependents to be insured: MEMBER SPOUSE

A Are you taking any prescribed medication or receiving or contemplating any medical attention or surgical treatment?YES

NO

YES

NO

B

During the past five years have you ever been medically diagnosed by a physician as having or been treated for: heart trouble, elevated blood pressure, gynecological or genitourinary disorders, ulcers, cancer, diabetes, mental or nervous disorder or psychotherapeutic treatment, epilepsy, respiratory disorder, kidney or liver disorder (including hepatitis), en-larged lymph nodes or immunodeficiency disorder, thyroid disorder, blood disorder, albumin, blood, pus, or sugar in urine, back trouble/disorder, arthritis, or unexplained weight loss?

C During the past five years have you been counseled, treated, or hospitalized for the use of alcohol or drugs?

G-29310-0 GMA-EZ2 1/21 ed

Depending on the amount of insurance you are requesting, you will be contacted by a service provider on behalf of New York Life Insurance Company to ask you about your medical history. What time and telephone number would be best to contact you? ________________________________________________________

Details (please fill out if answered “YES” to A, B, or C)


Member: YES NO

Spouse: YES NO


Member: $_________________ Spouse: $___________________


Member: $_________________ Spouse: $___________________

Company: _________________ Company: __________________

FRAUD NOTICE – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. The falsity of any statement in the application for any policy shall not bar the right to recovery under the policy unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer.

AUTHORIZATION & SIGNATURE: I understand that New York Life Insurance Company has the right to require additional information and, if necessary, an examination by a physician. I ask New York Life to rely on all such statements made on this form, and any supplements to it, while considering this request. I also understand that the coverage afforded will be in consideration of the answers and statements set forth above.

AUTHORIZATION: I hereby authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medical or medically related facility, laboratory, insurance company, MIB, Inc. (“MIB”), or other organization, institution or person, that has any records or knowledge of me or my health to release information, including prescription drug records, maintained by physicians, pharmacy benefit managers, and other sources of information to New York Life Insurance Company, its reinsurers, its subsidiaries or the plan administrator about the physical and mental health of any persons proposed for insurance, including significant history, findings, diagnosis and treatment, but excluding psychotherapy notes for the purpose of evaluating my application for insurance. Health information obtained will not be re-disclosed without my authorization unless permitted by law, in which case it may not be protected under federal privacy rules. For example, New York Life may be required to provide it to insurance, regulatory, or other government agencies. In this case, the information may no longer be protected by the rules governing your AUTHORIZATION.

A photocopy of this AUTHORIZATION and request form shall be as valid as the original. In all circumstances, my authorized agent, representative, or I may request a copy of this AUTHORIZATION. This AUTHORIZATION shall be valid for a period of 24 months from the date signed, unless sooner revoked. The AUTHORIZATION may be revoked at any time by sending written notice to New York Life Insurance Company. My revocation will not be effective to the extent that New York Life or any other person already has disclosed or collected information or taken other action in reliance on it, or to the extent that New York Life has a legal right to contest a claim under an insurance certificate or the certificate itself.

By signing and dating this application, I member/spouse request the insurance indicated; and the member and any person proposed for insurance consent to authorize the disclosure of information to and from the providers noted above and in the IMPORTANT NOTICE enclosed, including making a brief report of [my/our] protected health information to MIB, Inc.; and attest to having read the IMPORTANT NOTICE enclosed and Fraud Notice indicated above, including how [my/our] information is exchanged with MIB, and that to the best of [my/our] knowledge and belief, the answers provided to the questions are true and complete.

I hereby authorize the State Controller to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace Officers Association (CCPOA). The authorization will remain in effect until cancelled by me or by CCPOA. I certify that I am a member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.



G-29310-0 Retired Rollover Application 1/21 ed

“I hereby authorize the CalPERS to deduct from my salaries and wages the amount specified now or in the future for membership dues and any benefit program for which I have applied, which is sponsored by the California Correctional Peace Officers Association (CCPOA). This authorization will remain in effect until canceled by me or by CCPOA Benefit Trust Fund. I certify that I am a member of CCPOA and understand that termination of CCPOA membership will cancel all deductions made under this authorization.”





Retired Rollover MembersPlease complete and return this form to the Benefit Trust Fund

RETIRING AND HAVE TERM LIFE – USE THIS FORMSTL

Please Print Use Dark Ink Do Not Erase Initial All Changes. To continue coverage New York Life will rely on statements made by you in your latest application on file.

Office Use: Ret. Chp Eff Date:

Policyholder and Participating Organization:

CCPOA Benefit Trust FundPolicy No.

G29310Date of Retirement:

CCPOA Member’s Name (First, Middle Initial, Last) Male Female

Date of Birth:


City: Email: State Zip:

I have joined the CCPOA Retired Chapter and am seeking to rollover my Supplemental Term Life into retirement ________ (initial here)







For Retired CCPOA Member I hereby apply for a benefit amount of:

$____________________________________

For Office Use Only____________________________________________________________________

For Retired CCPOA Member’s Spouse I hereby apply for a benefit amount of:

$____________________________________ Please list spouse benefit amount you are applying for.

The spouse benefit amount must be no greater than 50% of the member’s coverage, up to $50,000



For Office Use Only____________________________________________________________________

If Spouse/Dependent Coverage is being continued, complete the following:


WHEN IS COVERAGE EFFECTIVE? The participant’s effective date of coverage shall be determined upon completion of your term life insurance conversion request, retirement date, and approval. The coverage will commence on the first (1st) day of the next calendar month immediately following the date on which a payroll deduction is made for your Retired Life insurance premium, provided you are a CCPOA retired chapter member on that date. You do not receive temporary or conditional insurance just because you submit a request for rollover.

Member Signature: Date:

Spouse Signature (if enrolling): Date:

A:34

We are the Plan Administrator for your insurance coverage with New York Life Insurance Company.

If you need assistance, please contact us at:

California Correctional Peace Officers Association Benefit Trust Fund 2515 Venture Oaks Way, Suite 200

Sacramento, CA 95833-4235

Telephone: (800) 468-6486

The address and toll-free number for the Consumer Affairs Unit of the California Department of Insurance is:

Consumer Services and Market Conduct Branch Consumer Services Division

300 South Spring Street, South Tower Los Angeles, CA 90013

Telephone: (800) 927-4357 (HELP)

However, the Department of Insurance has requested that we inform you that they are to be contacted only if discussions with us have failed to produce a resolution to the problem that is satisfactory to you.

NOTICE TO CALIFORNIA INSUREDS

ERISA DISCLAIMER: Please be aware that, depending on your circumstances and the product(s) you select, your group benefits plan may be subject to the Employee Retirement Income Security Act of 1974 (“ERISA”).

You should consult your tax and legal advisors regarding the applicability of ERISA to any arrangements addressed in this material. New York Life, its subsidiaries, agents, and employees do not provide legal, tax, or ERISA advice.

The tax consequences of benefits paid under this policy may depend on whether the employee pays for the coverage and to what extent the coverage is paid for on a pre- or post-tax basis, among other factors. Certain requirements apply to coverage offered under “cafeteria plans” subject to IRS sec. 125, including minimum eligibility and participation requirements. You should discuss with your tax advisor the consequences of buying this policy, including whether premium payments are deductible, the taxability of benefits; and whether you have met all applicable tax requirements. New York Life Insurance Company, its employees, agents, and affiliates cannot provide tax advice.

A:35

IMPORTANT NOTICE:

How New York Life Obtains Information and Underwrites Your Request For Group Supplemental Term Life Insurance

In this notice, references to “you” and “your” include any person proposed for insurance. Information regarding insurability will be treated as confidential. In considering whether the person(s) in your request for insurance qualify for insurance , we will rely on the medical information you provide, and on the information you AUTHORIZE us to obtain from your physician, other medical practitioners and facilities, other insurance companies to which you have applied for insurance and MIB, Inc. (“MIB”). MIB is a not-for-profit organization of insurance companies, which operates an information exchange on behalf of its members. If you apply for life or health insurance coverage, a claim for benefits is submitted to an MIB member company, medical or non-medical information may be given to MIB, and such information may then be furnished by MIB, upon request, to a member company.

Your AUTHORIZATION may be used for a period of 24 months from the date you signed the application for insurance, unless sooner revoked. The AUTHORIZATION may be revoked at any time by notifying New York Life in writing at the address provided. Your revocation will not be effective to the extent New York Life or any other person already has disclosed or collected information or taken other action in reliance on it, or to the extent that New York Life has a legal right to contest a claim under an insurance certificate or the certificate itself. The information New York Life obtains through your AUTHORIZATION may become subject to further disclosure. For example, New York Life may be required to provide it to insurance, regulatory or other government agencies. In this case, the information may no longer be protected by the rules governing your AUTHORIZATION.

MIB and other insurance companies may also furnish New York Life, its subsidiaries or the Plan Administrator with non-medical information (such as driving records, past convictions, hazardous sport or aviation activity, use of alcohol or drugs, and other applications for insurance). The information provided may include information that may predate the time frame stated on the medical questions section, if any, on this application. This information may be used during the underwriting and claims processes, where permitted by law.

New York Life may release this information to the Plan Administrator, other insurance companies to which you may apply for life and health insurance, or to which a claim for benefits may be submitted and to others whom you authorize in writing, however, this will not be done in connection with test results concerning Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV). We may also make a brief report of your protected health information to MIB, but we will not disclose our underwriting decision

New York Life will not disclose such information to anyone except those you authorize or where required or permitted by law. Information in our files may be seen by New York Life and Plan Administrator employees, but only on a “need to know” basis in considering your request. Upon receipt of all requested information, we will make a determination as to whether your request for insurance can be approved.

If we cannot provide the coverage you requested, we will tell you why. If you feel our information is inaccurate, you will be given a chance to correct or complete the information in our files. Upon written request to New York Life or MIB, you will be provided with non-medical information. Generally, medical information will be given either directly to the proposed insured or to a medical professional designated by the proposed insured. Your request is handled in accordance with the Federal Fair Credit Reporting Act procedures. If you question the accuracy of the information provided by MIB, you may contact MIB and seek a correction. MIB’s information office is: MIB, Inc., 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, telephone 866-692-6901 (TTY 866 346-3642). For Canadian residents, the address is: MIB Information Office, 330 University Avenue, Suite 501, Toronto, Ontario, Canada M5G 1R7, telephone 416-597-0590. Information for consumers about MIB may be obtained on its website at www.mib.com.

For NM Residents: Protected persons1 have a right of access to certain Confidential abuse information2 we maintain in our files and they may choose to receive such information directly. You have the right to register as a Protected person by sending a signed request to the Administrator at the address listed on the application. Please include your full name, date of birth and address.

Protected person means a victim of domestic abuse: who has notified us that he/she is or has been a victim of domestic abuse; and who is an 1insured person or prospective insured person.

Confidential abuse information means information about: acts of domestic abuse or abuse status; the work or home address or telephone 2number of a victim of domestic abuse; or the status of an applicant or insured as family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close, personal, family or abuse-related relationship.

New York Life Insurance Company 8.12 ed.

1-01-1003-03 BTF_COB_AppOnly.v1b_2021 Q221R07

Updated July 2021


1-800-468-6486

CCPOA Benefit Trust Fund

2515 Venture Oaks Way, Suite 200 Sacramento, CA 95833-4235

www.ccpoabtf.org

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

active & retired forms - ccpoabtf.org

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