Your Full Name:______________________________________________________SSN:_______________________________

Address:____________________________________________________Date of Birth:____________________________

City:_______________________________State:____________Zip:____________E-mail:__________________________

Institution:_________________________Job Classification:_____________________      o Male         o Female

Your Beneficiary:________________________________________Relationship: ____________________________

This coverage is valid upon receipt by the CCPOA Benefit Trust Fund until December 31, 2007. You will need to reapply in order to extend this coverage.
Please refer to the Plan’s Summary Plan Description for all particulars and exclusions.

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