btf icon

Forms & Publications

Accidental Death: Basic Accidental Death & Dismemberment Accident | Sickness Basic LIfe Gold Shield: Disability Legal Defense Fund CCPOA Medical Plan Piggyback Primary Dental Supplemental Term Life U.S. Legal VSP Western Dental Trust Forms & Docs

  Hot Items

  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
2025 Catalog of Benefits
 
Download PDF
All Members
2026 Price List
 
Download PDF
All Members
2026 Application Forms
RETIRED Applications
ACTIVE Applications
All Members
Beneficiary Change Form
 
Download PDF

Member Benefits

ADB_PlanIcons
$5,000 Accidental Death Basic
Active
Summary Program Description
 
Download PDF
ADD_PlanIcons
Accidental Death & Dismemberment
Active
Application
 
Download PDF
Active
Brochure
 
Download PDF
Active
Plan Certificate 29312-0
 
Download PDF
Retired
Application
 
Download PDF
Retired
Plan Certificate 29313-0
 
Download PDF
PB_PlanIcons
Accident & Sickness Programs - ARG Benefits   
All Members
A|S: Applications
Corey Gonsalves: Member Service Supervisor
888-211-6157
All Members
A|S: Claim Form
Download PDF
All Members
A|S: Brochure
 
Download PDF
All Members
Accident Plus: Certificate of Coverage 
 
Download PDF
All Members
Shield Plus: Certificate of Coverage 
 
Download PDF
BL_PlanIcons
Basic Life
Active
Plan Certificate 29307-0
 
Download PDF
Retired
Plan Certificate 29308-0
 
Download PDF
DBP_PlanIcons
Gold Shield: Disability Benefit Program
Active
Gold Shield: Application
 
Download PDF
Active
Gold Shield: Brochure
 
Download PDF
CLOSED
Gold/Silver Shield: Compairison Chart
Silver Shield is CLOSED to new enrollment
 
Download PDF
Active
Upgrade from Silver Shield
 
Download PDF
Active
Summary Program Description
 
Download PDF
LDF_PlanIcons
Legal Defense Fund
Active
Summary Program Description
 
Download PDF
Active
Summary Material Modification (04/2023)
 
Download PDF
MP_PlanIcons
Medical Plan
Blue Shield CCPOA Member Site
Active
2026 Evidence of Coverage (EOC)
Download PDF
Active
2026 Summary of Benefits & Coverage (SBC)
Download PDF
Active
2026 Summary of Benefits (SOB)
Download PDF
Retired
2026 Medicare Evidence of Coverage (EOC)
Download PDF
Retired
2026 Medicare Summary of Benefits (SOB)
Download PDF
Retired
2026 Medicare Pharmacy Directory
 Visit Blue Shield
 
All Members
Teledoc HIPPA Release Form
Download PDF
PB_PlanIcons
Piggyback
Active
Application
 
Download PDF
Active
Vision Claim Form
 
Download PDF
Retired
Application
 
Download PDF
Retired
Vision Claim Form
 
Download PDF
All Members
Piggyback Brochure
 
Download PDF
All Members
Summary Plan Description
 
Download PDF
PD_PlanIcons
BTF Core Dental
Active
Brochure
 
Download PDF
Active
Plan Highlights
 
Download PDF
Active
Claim Form
 
Download PDF
Active
Summary Program Description
 
Download PDF
STL_PlanIcons
Supplemental Term Life
All Members
Brochure
 
Download PDF
All Members
2026 STL Application Forms
RETIRED Applications
ACTIVE Applications
Active
Plan Certificate 29307-0
 
Download PDF
Retired
Plan Certificate 29308-0
 
Download PDF
Retired
Plan Certificate 29310-0
 
Download PDF
CLOSED
Senior Term Life Closed to new enrollment
Plan Certificate 29309-0
 
Download PDF
USL_PlanIcons
MetLife - Legal PLan 
Active
Brochure
 
Download PDF
Retired
Application
 
Download PDF
Active
Summary Program Description: Active
 
Download PDF
Retired
Summary Program Description: Retired
 
Download PDF
VSP_PlanIcons
VSP - Vision PLan
Retired
Application
 
Download PDF
Retired
Brochure
 
Download PDF
All Members
Summary Program Description
 
Download PDF
All Members
Out-Of-Network Reimbursement Form
Download PDF
All Members
VSP Privacy Notice
Download PDF
All Members
VSP Grievance Process
Download PDF

Benefit Trust Forms & Docs

PB_PlanIcons
Benefit Trust Fund

Member/Dependent Update Forms:

All Members
Beneficiary Change Form
 
Download PDF
All Members
MyBenefits: Member Profile Form
Download PDF
All Members
MyBenefits: Dependent/Proxy Authorization
Download PDF
All Members
MyBenefits: Dependent/Proxy Cancellation
Download PDF
Benefit Trust Fund Plan Documents:
Plan Details
Notice of Privacy Practices
 
Download PDF
Plan Details
Agreement & Declaration of Trust
 
Download PDF
Plan Details
Welfare Benefit Plan (Plan 501)
 
Download PDF
Plan Details
Disability Benefit Plan (Plan 502)
 
Download PDF
Plan Details
Supplemental Benefit Plan (Plan 503)
 
Download PDF
Plan Details
Medical Plan
 
Download PDF
Plan Details
Summary Annual Report
 
Download PDF
Plan Details
New York Life: Summary Program Description
 
Download PDF
Go To Top