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

Documents & Forms

  • Member Benefits
  • Member Forms
  • 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
Combined Insurance
Combined Insurance: Brochure
Combined Insurance: Claim Form
Disability Benefit Program (DBP)
Gold Shield: Brochure
Gold Shield: New Officer 50% Discount Application
Gold Shield/Silver Shield: Comparison Chart
Gold Shield/Silver Shield: Application
Upgrade from Silver Shield
Cadet Basics Flyer
DBP: Summary Program Description
Dental
Primary Dental
Primary Dental: Brochure
Primary Dental: Claim Form
Primary Dental: Plan Highlights
Primary Dental: Procedure Codes
Primary Dental: Summary Plan Description
Western Dental
Western Dental: Summary Material Modification
Western Dental: Summary Plan Description
Legal Programs
Legal Defense Fund (LDF)
LDF: Summary Plan Description
U.S. Legal Services
U.S. Legal: Brochure
U.S. Legal: Non-Network Claim Form
U.S. Legal: Privacy Form
U.S. Legal: MSA Financial Counseling
Retired: U.S. Legal Application
U.S. Legal: Summary Program Description
CCPOA Medical Plan
Active: 2016 E-Z Summary
Active: 2016 Medical Plan-Evidence of Coverage
Retired: 2016 E-Z Summary
Retired: 2016 Medical Plan-Medicare-Evidence of Coverage
Retired: 2017 Prescription Drug Plan
Retired: Prescription Drug Plan Application
Teladoc: Quick Start
CVS Member Brochure
Health Advocate Brochure
Walgreens Patient Plan
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-2016 Rate Sheet
Active: STL- Active Brochure/Application
Active: STL- Plan Certificate 29307-0
Retired: STL-2016 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
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: 2016 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
2018 Health Benefit Summary
2017 Health Benefit Summary
The Benefit Trust Fund is not responsible for the accuracy of CalPERS information.
Always check with CalPERS for the latest updates.