Association Application for Participation Name of Association*Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Authorized Representative*Phone*Email* Alternate Authorized Representative*Phone*Email* Total Number of Members in the Association*Does the Association cover PMA?*YesNoHow many?TypeDoes the Association cover Non-Sworn?*YesNoHow Many?TypeDoes the Association cover part-time, seasonal or volunteer workers?*YesNoHow many?TypeCheck 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 ControlHigher Quality BenefitsThe 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?*YesNoPlease refer to the IBT’s Participation Policy for participation guidelines.Carrier NameThe 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
