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Forms & Publications

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Beneficiary Change Form
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Catalog of Benefits
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Application Forms Booklet
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Price List
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Join the CCPOA
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Member Benefits

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$5,000 Accidental Death Basic
Active
Summary Program Description
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Accidental Death & Dismemberment
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Application
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Brochure
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Active
Plan Certificate 29312-0
 
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Retired
Application
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Plan Certificate 29313-0
 
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Basic Life
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Plan Certificate 29307-0
 
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Plan Certificate 29308-0
 
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Disability Benefit Program: Gold Shield
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Gold Shield: Application
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Active
Gold Shield: Brochure
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CLOSED
Gold/Silver Shield: Compairison Chart
Closed to new enrollment
 
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Active
Upgrade from Silver Shield
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Summary Program Description
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Legal Defense Fund
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Summary Program Description
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Active
Summary Material Modification (04/2023)
 
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Medical Plan
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2024 Summary of Benefits & Coverage (SBC)
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Active
2024 Evidence of Coverage (EOC)
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Active
2024 Summary of Benefits (SOB)
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Active
2024 Prescription Drug Plan (SOB)
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Active
2024 Drug Formulary
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Retired
2024 Medical Plan: Medicare (EOC)
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Retired
2024 CCPOA Medical Plan: Medicare (SOB)
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2024 Medicare Drug Step-Therapy
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2024 Medicare Pharmacy Directory
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Download PDF-Spanish
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2024 Medicare Drug Formulary
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2024 Chiropractic Plan (SOB)
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All Members
Teledoc HIPPA Release Form
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Piggyback
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Application
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Active
Vision Claim Form
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Retired
Application
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Retired
Vision Claim Form
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Piggyback Brochure
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Summary Plan Description
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Primary Dental
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Brochure
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Plan Highlights
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Active
Claim Form
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Summary Program Description
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Supplemental Term Life
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Brochure/Application
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Active
Plan Certificate 29307-0
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Retired
Plan Certificate 29308-0
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Retired
Plan Certificate 29310-0
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CLOSED
Senior Term Life Closed to new enrollment
Plan Certificate 29309-0
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Vault: Accident & Sickness Programs 
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VAULT Applications
Corey Gonsalves: Member Service Supervisor
888-211-6157
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VAULT Claim Form 
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VAULT Brochure 
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Accident Champion: Certificate of Coverage 
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Shield Plus: Certificate of Coverage 
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U.S. Legal Services: Family Defender 
Active
Brochure
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Retired
Application
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Non-Network Claim Form
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All Members
Privacy Form
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All Members
Summary Program Description
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VSP
Retired
Application
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Retired
Brochure
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Summary Program Description
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Out-Of-Network Reimbursement Form
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Western Dental
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Summary Material Modifications
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Summary Program Description
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Benefit Trust Forms & Docs

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Benefit Trust Fund

Member/Dependent Update Forms:

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Beneficiary Change Form
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All Members
MyBenefits: Member Profile Form
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MyBenefits: Dependent/Proxy Authorization
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MyBenefits: Dependent/Proxy Cancellation
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Benefit Trust Fund Plan Documents:
Plan Details
Notice of Privacy Practices
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Plan Details
Agreement & Declaration of Trust
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Plan Details
Welfare Benefit Plan (Plan 501)
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Plan Details
Disability Benefit Plan (Plan 502)
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Plan Details
Supplemental Benefit Plan (Plan 503)
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Plan Details
Medical Plan
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Plan Details
Summary Annual Report
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Plan Details
New York Life: Summary Program Description
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