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Forms & Publications

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  JOIN THE CCPOA: ON-LINE APPLICATION

If you have any questions about CCPOA Membership, please contact: membership@ccpoa.org or call 1-800-821-6443

All Members
2027 Catalog of Benefits
 
Coming Soon
All Members
2027 Price List
 
All Members
Application Forms
All Members
Beneficiary Change Form
 

Member Benefits

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$5,000 Accidental Death Basic 
Active
Summary Program Description
 
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Accidental Death & Dismemberment - MetLife
Active
Application
 
Active
Brochure
 
Coming Soon
Retired
Application
 
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Accident & Sickness Programs - ARG Benefits   
All Members
A|S: Applications & Claims
Corey Gonsalves: Member Service Supervisor
888-211-6157
All Members
A|S: Brochure
 
All Members
Accident Plus: Certificate of Coverage 
 
All Members
Shield Plus: Certificate of Coverage 
 
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Basic Life - MetLife
Active
No Application Required
 
Retired
No Application Required
 
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BTF Core Dental - United Concordia
Active
Brochure
 
Active
Plan Highlights
 
Active
Summary Program Description
 
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Gold Shield: Disability Benefit Program
Active
Gold Shield: Application
 
Active
Gold Shield: Brochure
 
Active
Summary Program Description
 
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Legal Defense Fund
Active
Summary Program Description
 
Active
2027 Evidence of Coverage (EOC)
Active
2027 Summary of Benefits & Coverage (SBC)
Active
2027 Summary of Benefits (SOB)
Retired
2027 Medicare Evidence of Coverage (EOC)
Retired
2027 Medicare Summary of Benefits (SOB)
Retired
Medicare Pharmacy Directory
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Piggyback Dental
Active
Application
 
Retired
Application
 
All Members
Piggyback Brochure
 
All Members
Summary Plan Description
 
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Supplemental Term Life - MetLife
Active
Active Term Life Application
 
Active
Guarantee Issue: Active Term Life
 
Retired
Retired Term Life Application
 
Retired
Retired Roll-Over Term Life Application
 
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CCPOA Vision Plan - VSP
Retired
Application
 
Retired
Brochure
 
All Members
Summary Program Description
 

Benefit Trust Forms & Docs

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Benefit Trust Fund

Member/Dependent Update Forms:

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