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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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Active
Brochure
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Active
Plan Certificate 29312-0
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Retired
Application
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Retired
Plan Certificate 29313-0
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Basic Life
Active
Plan Certificate 29307-0
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Retired
Plan Certificate 29308-0
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Disability Benefit Program: Gold Shield
Active
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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Active
Summary Program Description
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Legal Defense Fund
Active
Summary Program Description
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Medical Plan
Active
2024 Summary of Benefits & Coverage (SBC)
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Active
2023 Evidence of Coverage (EOC)
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Active
2023 Summary of Benefits & Coverage (SBC)
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Active
2023 Summary of Benefits (SOB)
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Active
2023 Prescription Drug Plan (SOB)
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Active
2023 Drug Formulary
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Retired
2023 Medical Plan: Medicare (EOC)
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Retired
2023 CCPOA Medical Plan: Medicare (SOB)
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Retired
2023 Medicare Pharmacy Directory
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Download PDF-Spanish
Retired
2023 Medicare Drug Formulary
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2023 Chiropractic Plan (SOB)
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Piggyback
Active
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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All Members
Summary Plan Description
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Primary Dental
Active
Brochure
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Active
Plan Highlights
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Active
Claim Form
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Active
Out-Of-Network Fee Schedule
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Active
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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Triada Insurance
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Triada Brochure
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Triada Application
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Triada Claim Form
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All Members
Accident Defender: Flyer
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Accident Defender: Plan Certificate
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All Members
Shield Plus: Flyer
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Shield Plus: Plan Certificate
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Closed
LEGACY: Accident Champion Certificate
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Closed
LEGACY: ADP Certificate
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Closed
LEGACY: DAP Certificate
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Closed
LEGACY: SDP Certificate
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U.S. Legal Services: Family Defender 
Active
Brochure
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Retired
Application
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All Members
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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Western Dental
Active
Summary Material Modifications
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Active
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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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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Claims Dept: (916) 779-6356

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CCPOA Benefit Trust Fund
2515 Venture Oaks Way
Suite 200
Sacramento, CA 95833

© 2020 CCPOA Benefit Trust Fund
TWO TOWERS logo is a registered trademark of CCPOA Benefit Trust Fund

All the information on this website is published in good faith and for general information purpose only. Benefit Trust Fund does not make any warranties about the completeness, reliability and accuracy of this information. This website explains the general purpose of the insurance described, but in no way changes or affects any policy as actually issued. In the event of a discrepancy between this website and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy.  NYL#5032877.3  EXP 5/11/25