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Myers-Stevens Addl AD&D Coverage application

It’s Simple To Enroll

Using the AD&D enrollment Form:

  1. Complete all member and beneficiary information
  2. Check the box(es) next to the selections that best fit your needs.
  3. Check the box (es) for spouse and/or children’s selections if you want this added protection, otherwise only the member will be insured.
  4. Premiums will be deducted monthly from your payroll if the service is available. If not, you will be billed quarterly, semi-annually, or annually by Myers-Stevens & Toohey & Co., Inc. Retired members will also be billed quarterly, semi-annually, or annually.
  5. Don’t forget to SIGN and DATE your enrollment form.
  6. Submit your enrollment form by either:
    • Send completed for to WPOA and they will transmit it to Myers-Stevens & Toohey.

Full Name
MM slash DD slash YYYY
Home Address
Full name of your Department
(Example Jane Doe, not Mrs. Jane Doe. The member is the beneficiary on any coverage in offers and his/her dependents.
As a member in good standing of the Peace Officer’s Research Association of California and having read the brochure, I hereby request to participate in the Accidental Death & Dismemberment Insurance plan sponsored by Insurance and Benefits Trust of PORAC and underwritten by Reliance Standard life Insurance Company. I agree that premiums, if required, for this insurance shall be paid by payroll deduction, if available, otherwise as billed by Myers-Stevens & Toohey Co., Inc. Coverage shall be effective on the first day of the month following receipt of this completed enrollment form by Myers-Stevens & Toohey Co., Inc. provided any required premiums are paid when billed. If payroll deduction is not available, I prefer to pay premiums
MM slash DD slash YYYY
Policy No. SR 228250 (CORE AD7D) Policy No. VAR 100.005 (Voluntary AD&D)