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Apply English

English

CCPU Health Care Fund Application Form (English)
PDF • Application Form
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English

Voluntary Life Application (English)
PDF • Voluntary Life Form
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English

Beneficiary Designation/Change Form (English)
PDF • Beneficiary Form
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English

CCPU Dependent Application English
PDF • Application Form
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Reimbursement English

English

CCPU Health Care Fund Reimbursement Request Form (English)
PDF • Reimbursement Request Form
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Auth Form - English

English

CCPU Health Care Fund Authorization Form (English)
PDF • Authorization Form
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Am I eligible for CCPU Heathcare Reimbursement Fund benefits?

Answer these simple questions to determine your potential program eligibility.

To complete your application online, you’ll need proof of coverage for your health plan (a document showing your name as the policyholder, the name of your insurance plan, the coverage period, and the amount you pay for coverage).

If you don’t have an account for the CCPU Health Care Fund portal, you can sign up now with your email address and mobile phone number.

Questions? Call the PRC at (888) 583-CCPU(2278) or Email: [email protected]