btf icon

Forms & Publications

  Hot Items

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

Member Benefits


ADB_PlanIcons
$5,000 Accidental Death Basic
Active
Summary Program Description
ADD_PlanIcons
Accidental Death & Dismemberment
Active
Application
Active
Brochure
Active
Plan Certificate 29312-0
Retired
Application
Retired
Plan Certificate 29313-0
BL_PlanIcons
Basic Life
Active
Plan Certificate 29307-0
Retired
Plan Certificate 29308-0
DBP_PlanIcons
Disability Benefit Program: Gold Shield
Active
Gold Shield: Application
Active
Gold Shield: Brochure
CLOSED
Gold/Silver Shield: Compairison Chart
Closed to new enrollment
Active
Upgrade from Silver Shield
Active
Summary Program Description
LDF_PlanIcons
Legal Defense Fund
Active
Summary Program Description
MP_PlanIcons
Medical Plan
Active
2024 Summary of Benefits & Coverage (SBC)
Active
2023 Evidence of Coverage (EOC)
Active
2023 Summary of Benefits & Coverage (SBC)
Active
2023 Summary of Benefits (SOB)
Active
2023 Prescription Drug Plan (SOB)
Active
2023 Drug Formulary
 
Retired
2023 Medical Plan: Medicare (EOC)
Retired
2023 CCPOA Medical Plan: Medicare (SOB)
Retired
2023 Medicare Pharmacy Directory
Retired
2023 Medicare Drug Formulary
All Members
2023 Chiropractic Plan (SOB)
PB_PlanIcons
Piggyback
Active
Application
Active
Vision Claim Form
Retired
Application
Retired
Vision Claim Form
All Members
Piggyback Brochure
All Members
Summary Plan Description
PB_PlanIcons
Primary Dental
Active
Brochure
Active
Plan Highlights
Active
Claim Form
Active
Out-Of-Network Fee Schedule
Active
Summary Program Description
PB_PlanIcons
Supplemental Term Life
All Members
Brochure/Application
Active
Plan Certificate 29307-0
Retired
Plan Certificate 29308-0
Retired
Plan Certificate 29310-0
CLOSED
Senior Term Life Closed to new enrollment
Plan Certificate 29309-0
PB_PlanIcons
Triada Insurance
All Members
Triada Brochure
All Members
Triada Application
All Members
Triada Claim Form
All Members
Accident Defender: Flyer
All Members
Accident Defender: Plan Certificate
All Members
Shield Plus: Flyer
All Members
Shield Plus: Plan Certificate
Closed
LEGACY: Accident Champion Certificate
Closed
LEGACY: ADP Certificate
Closed
LEGACY: DAP Certificate
Closed
LEGACY: SDP Certificate
PB_PlanIcons
U.S. Legal Services: Family Defender 
Active
Brochure
Retired
Application
All Members
Non-Network Claim Form
All Members
Privacy Form
All Members
Summary Program Description
PB_PlanIcons
VSP
Retired
Application
Retired
Brochure
All Members
Summary Program Description
PB_PlanIcons
Western Dental
Active
Summary Material Modifications
Active
Summary Program Description


Benefit Trust Forms & Docs

PB_PlanIcons
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
Plan Details
New York Life: Summary Program Description
Go To Top
go home button

Call Us

FAX:

Main Office: (916) 779-6355
Claims Dept: (916) 779-6356

Toll Free: 1-800-In-Unit-6

Visit Us

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