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Please confirm you are a Safety Member by initialing the space below.

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.