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PYI Application
CPF Members
Apply NOW for PYI!
(seasonal firefighters not eligible)

Instructions: Complete each section of this application, including all details of any injury or illness for which you received (or should have received) medical treatment, counseling, or therapy. Failure to disclose a pre-existing condition or injury may result in a denial of your claim for benefits under the PYI plan. Be accurate, and thorough in your description of any previous injury, condition, or illness that required medical attention.
 
Name
Address City State Zip
Home Ph ( ) Work Ph ( ) Email
SSN - -      DOB / /       Monthly Salary $
Hire Date (permanent civil service employee) / /      Classification/Rank
Marital Status      Name of Spouse
 
Are you actively at work?
        If no and you are off on a disability, what is your anticipated Return to Work date? / /
 
Local Number
Have you or your spouse used ANY TYPE of tobacco in the past 12 months?   Member: Spouse:
 
Would you like to know more about the life, home, dental or auto insurance benefits available through the CPF Health Benefits Trust? 
 
Beneficiary (Name) Relationship
 
1. A) Have you ever; (a) had, (b) been advised by a physician that you had, or (c) received advice or treatment for:
(If you are not sure about an answer, your physician will be able to provide you with the information.)
 

  B) High blood pressure?
  C) Diabetes?
  D) Cancer, leukemia, malignant growth, or any form of tumor?
  E) Epilepsy or any mental/nervous disorder?
  F) Alchoholism, or any drug or substance abuse?
 
G)  a. Any disorder of the immune system, including AIDS and AIDS Related Complex?
b. Tested positive for antibodies to AIDS (human immunodeficiency virus; HIV)
2. Other than the above, have you in the past five years had any disorder or injury not listed here?
3. Have you had a physical examination in the past five years?
4.
A) Are you under medical observation for any reason?
B) Are you taking medication for any reason?
Condition Medication Dosage & Frequency

If any Yes answers to questions 1 through 4 please explain below.
Ques
No 		Name of Individual Condition, injury, symptom, of ill health or
findings of examination (if surgery
performed, state type) 		Onset date
Month/Year 		Date of Last
treatment 		Degree of
recovery 		Name and address of
attending physician

IF HOSPITALIZED, NAME AND ADDRESS OF HOSPITAL

I HEREBY (1) request coverage under the Protect Your Income plan as described in the Certificate of Coverage prepared by the California Professional Firefighters Health Benefits Trust, (2) authorize the required deductions, if any, from my earnings; (3) represent that my answers to the forgoing questions, and any statements made above are true and complete, and that every occasion and instance to each item answered "yes" has been disclosed; (4) understand that among the requirements for participation in the PYI plan is that I remain a member in good standing of the California Professional Firefighter and am actively at work as a firefighter.
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