If you would like to enroll in the CCPOA Accidental Death and Dismemberment plan, please complete the application and mail it into the Trust. If you have any questions, please contact the Trust at 1-800 IN UNIT 6.

Click below to download a pdf of the files you need.

Brochure

Application

Who is eligible?
You are if you are a retired dues paying member. A spouse under age 70 and unmarried dependent children under the age 23 who are full time students are also eligible.

When am I covered?
You are covered 24 hours a day anywhere in the world. These benefits are payable in addition to any other insurance you have.

What are the benefits?

• Spouse Education Benefit - This benefit will be the lesser of 5% of your Principle Sum, Expense Incurred for Occupational Training, or the maximum amount of $5,000.
  
  To qualify for this benefit, your spouse must enroll in an Occupational Training Program for the purpose of earning an independent income. Enrollment must take place within one year of your death, and expenses must be incurred within two years of you death.

  If the Principle Sum is payable because of your death, and no covered spouse survive, the plan will pay the minimum of $1,000 according to the terms of the beneficiary section.

  Expenses Incurred means actual tuition charged and cost of materials required for the Occupational Training Program. It does not include room and board.

  Occupational Training Program means any education, professional, or trade training which prepares your spouse for an occupation for which he or she would not otherwise qualify.

• Common Disaster Benefit - If you and your spouse die as a result of injuries received in the same accident and a Principle Sum is payable under the AD&D Benefit for each death, the benefit for your spouse will be increased to equal the lesser of your Principle Sum or an amount which when added to your Principle Sum equals $300,000-up to a maximum benefit of $200,000.

If an injury results in any of the following losses within 365 days after the accident, this plan will pay for loss of:

• Life - The Principle Sum
• Both hands or both feet or sight in both eyes - The Principle Sum
• One hand and one foot - The Principle Sum
• Speech and Hearing - The Principle Sum
• Either Hand or Foot and Sight of one Eye - The Principle Sum
• Movement of Both Upper and lower Limbs (Quadriplegia) - The Principle Sum
• Movement of both Lower Limbs (Paraplegia) - ¾ of the Principle Sum
• Movement of Both Upper and Lower Limbs of one side of the body (Hemiplegia) - ½ of the Principle Sum
• Either Hand or Foot - ½ of the Principle Sum
• Sight of One Eye - ½ of the Principle Sum
• Speech or Hearing - ½ of the Principle Sum
• Thumb and Index Finger of Either Hand - ¼ of the Principle Sum

Definition of Loss
In regards to hands, feet, and actual severance through or above wrist or ankle joints; sight,speech or hearing, entire and irrecoverable loss thereof. In regards to thumb and index finger, actual severance through or above the metacarpophalangeal joints. In regards to movement of limbs, complete and irreversible paralysis of such limbs.

Definition of Injury
Injury means a bodily injury resulting directly from an accident and independent of all other causes. Loss resulting from sickness or disease, or medical or surgical treatment of a sickness is not covered. The accident must occur while you are covered under the policy.

Are there any exclusions?
Loss caused by any of the following events is not covered:

• Intentional, self-inflicted injury, suicide or attempted suicide, whether sane or insane
• War or act or war, whether declared or undeclared
• Injury sustained while riding aircraft unless it’s a civilian or public aircraft or military transport aircraft
• Injury sustained with riding on any aircraft as a pilot, crew member, student pilot, flight instructor or examiner
• Injury sustained while riding on any aircraft owned, operated or leased by or for the policyholder or any employer or organization whose eligible persons are covered under the policy

What is the cost?
You select you principle Sum from the following table:
Monthly Cost Via Retirement Benefit Deductions Principal Member Family Sum Only Plan $25,000 $1.60 $2.13 50,000 3.19 4.25 75,000 4.79 6.38 100,000 6.38 8.50

• In addition to your own coverage, family cover provides the following insurance for your dependents
• If you have a spouse only, the spouse if insured for 50% of your Principle Sum
• If you have a spouse and children, your spouse s insured for 40% of your Principle Sum and each unmarried child under age 19 (23 for full-time students) is insured for 10% of you Principle Sum
• If you have children only, each child is insured for 15% of your Principle Sum to age 19 (23 if full-time student)

When will my coverage become effective?
Retired CCPOA Member and new Retired Members – Continuous open enrollment period. If your application is received before the 8th of the current month, your coverage will become effective on the first day of the month immediately following the pay period from which the first premium deduction is taken from your CalPERS retirement benefit.

Who will be the beneficiary?
Benefits for loss of life will be paid to the beneficiary you have designated. If you have not designated a beneficiary, the life benefit will be paid to your estate. Benefits for loss other than life will be paid to you.

For more information on Accidental Death and Dismemberment coverage offered for Retired CCPOA members, please contact the CCPOA Benefit Trust Fund.