Upcoming Events

Dec
14
Wed
E-Board Meeting
Dec 14, 2022
REACT Center
Jan
11
Wed
General Membership Meeting
Jan 11, 2023
Big Sky Conference Room
Feb
08
Wed
E-Board Meeting
Feb 08, 2023
REACT Center
Mar
08
Wed
General Membership Meeting
Mar 08, 2023
Big Sky Conference Room
Apr
12
Wed
E-Board Meeting
Apr 12, 2023
REACT Center



Tell Us About Yourself:

Your Name *
Sex *
SSN *
Home Address *
City *
State *
Zip *
Date of Birth *
E-Mail Address *
Home Phone *
Work Phone *
Full Name of Your Employer *
Date Employed *
Association Name *
Associate Number
Monthly Salary
$
Date of PORAC Membership
PORAC Number (if available)
Please confirm you are a Safety Member by initialing the space below.
I am a Safety Member:
Safety Member is an employee who is eligible to receive benefits under California Labor Code Section 4850 and safety employee benefits under the County Employees Retirement Act of 1937 or Public Employees Retirement Systems (PERS) of California, or benefits comparable 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 my 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 to make the necessary deductions from my wages or salary to cover my contribution (if any) for the cost of this coverage.
Member’s Signature *

Use your mouse, finger, or touch device to write your signature.
Date *






  • Stanislaus County DSA

    Copyright © 2022. All Rights Reserved.

    Powered By UnionActive


  • Top of Page image