Association Application for Participation Name of Association* Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Authorized Representative* Phone*Email* Alternate Authorized Representative* Phone*Email* Total Number of Members in the Association*Does the Association cover PMA?* Yes No How many?Type Does the Association cover Non-Sworn?* Yes No How Many?Type Does the Association cover part-time, seasonal or volunteer workers?* Yes No How many?Type Check the benefit(s) your Association is interested in participating in* Long Term Disability CalPERS Health VSP Vision AFLAC Term Life California Casualty Auto/Home If interested in Health insurance, what dollar or percentage of premium does the employee pay towards coverage? Please refer to the IBT’s Participation Policy for participation guidelines.Regarding Health insurance, what is most important to your group?* Cost Control Higher Quality Benefits The Undersigned understands that the Insurance and Benefits Trust of PORAC (the “IBT”) limits the number of Non-Sworn employees covered under the health plan to not more than 20% of the total Association’s membership.If interested in Disability insurance, does the Association currently have coverage?* Yes No Please refer to the IBT’s Participation Policy for participation guidelines.Carrier Name The Undersigned acknowledges that he/she has the authority to execute this document on behalf of the above described Association (the “Association”). The Undersigned further acknowledges that any benefits approved are conditioned on the Association’s continuing membership in good standing with PORAC and that this requirement has been communicated to the Association’s members. The Undersigned understands that if the Association withdraws from PORAC, all Trust benefits for the Association’s members will be terminated. Lastly, the Undersigned acknowledges that he/she has read and understands the IBT’s Participation Policy and this form, that the information provided in this application is true and correct, that the contents of this form are binding on the Association and any successors thereto, and that the IBT will rely on the information.Digital Signature of Authorized Representative* Name* First Last Title* Date* MM slash DD slash YYYY CAPTCHAPlease enter the following characters in the field below.PhoneThis field is for validation purposes and should be left unchanged. Δ
