Insurance & Benefits Trust / Committee of PORAC

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Association Application for Participation

Name of Association*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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*
Date Format: MM slash DD slash YYYY