Individual Application for Sponsoring Membership

Peace Officers Research Association
of California
Insurance & Benefits Trust
SPONSORSHIP APPLICATION FOR PARTICIPATION
Individual Seeking Coverage
Applicant(s) Name(s):
Mailing Address:
Contact Phone Numbers: Home)
Other type
#
Email Address
Applicant’s Relationship to Sponsoring Association
Reason for Needing Sponsorship:
Circle the product(s) you are requesting to participate in:
Long Term Disability
CalPERS Health
AFLAC
Term Life
California Casualty Auto/Home
The Undersigned acknowledges that any benefits approved are done so with the understanding that I must remain a
member in good standing with PORAC and that my Sponsoring Association must also remain a member in good standing
with PORAC. If my Sponsoring Association withdraws from PORAC, all of my Insurance and Benefits Trust of PORAC
(“Trust”) benefits will be terminated. The Undersigned further acknowledges that I have read and understand the Trust’s
Benefit Eligibility Policy and this form, that the information provided in this application is true and correct and that the Trust
will rely on the information.
Applicant(s) Signature:
Date:
Sponsoring Association
Sponsoring Association Name:
Authorized Representative:
Phone: 1)
2)
e-mail:
The Undersigned acknowledges that I have the authority to execute this document on behalf of the above described
Sponsoring Association (the “Sponsoring Association”). The Undersigned acknowledges that any benefits approved for
the individual described above are conditioned on the Sponsoring Association remaining a member in good standing with
PORAC. I understand that if the Sponsoring Association withdraws from PORAC, all Trust benefits for the above
individual will be terminated. The Undersigned further acknowledges that he or she has read and understands the Trust’s
Benefit Eligibility 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 Sponsoring Association and any successors thereto, and that the Trust will rely on the
information.
Signature of Authorized Representative:
Title:
Date:
Please return application to:
4010 Truxel Rd Sacramento, CA 95834 • (800) 655-6397 • FAX (916) 999-8892 • (800) 937-6722
EMAIL: mjimenez@porac.org • WEBSITE: www.porac.org/insurance-and-benefits/