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Myers Stevens Application for Group Disability

Group Disability Application

GOLD – Group Short/Long Term Disability Program

DIRECTIONS: This form must be completed to apply for Group Disability Coverage. When evidence of insurability is required, that form will be provided separately. To apply for coverage (as a Member read the notice(s) on back page of application; then complete all items, sign and date below.

When finished send to WPOA Representative who will submit it to Myers-Stevens & Toohey & Co., Inc. Keep a copy for your records.

Myers-Stevens & Toohey & Co., Inc. / 26101 Marguerite Parkway / Mission Viejo / CA 92692

Phone: 800-827-4695 / porac@MYERS-STEVENS.COM / License #0425842

Insurance & Benefits Trust of PORAC (std Plan 610007 - $)
Standard Insurance Company (LTD Policy 649401 – A)

Tell Us About Yourself:

Your Name
Home Address
MM slash DD slash YYYY
Full name of your employer
MM slash DD slash YYYY
Safet Association Name Whittier Police Officers’ Association
MM slash DD slash YYYY
Safety member is an employee who is eligible to receive benefits under California Labor Code Section 4850 and safety employee benefits for County Employees Retirement Act of 1937 or Public Employees Retirement Systems PERS of California thereto with their employer at the time of Disability is incurred. As a member in good standing of PORAC and having read the attached brochure describing the benefits, I hereby apply for coverage under the association’s disability plan which is subject to the provisions of the Insurance and Benefits Trust of the Peace Officers Research Association of California Group Short Term Disability Plan Document and the Standard Long Term Disability Policy. I certify that I am working full-time and able to perform all the required duties of my occupation. Upon approval of this application, I authorize my employer o make the necessary deductions from my wages or salary to cover my contribution (if any): for the cost of this coverage.