Forms

Forms

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Enrollment

LINECO Family Enrollment Card - Use this form to enroll your family in the Plan.

Death Beneficiary Card - Use the family enrollment card to designate a beneficiary in case of participant's death.

Authorization to Disclose Health Information - Participants may use this form to authorize the disclosure of health information in order to enable another person or organization to assist you in obtaining benefits from the Fund.

Change of Address - Use this form to notify the Fund of a change of address.

Full Time Student Verification - For dependent child age 19 (other than biological/step-child) attending an accredited secondary school, college, university, vocational or technical school.

Provider Work/Military Related Accident/Injury - To be used by the treating Physician.

Employee Accident Questionnaire - To be completed by the employee giving details of accident/injury.

Common Law Affidavit - To be signed by employee and common law spouse. The document must be notarized and returned to Lineco.

Employee Other Insurance Verification - This form must be completed and signed by the employee indicating any other coverage that the employee or dependents may have.

Authorization to Release Information - To be completed by the employee/patient giving approval for a specific hospital, physician or other person to release information required for claim review.

HRA Reimbursement Request Form - This form must be completed by the Lineco HRA member to request reimbursement for eligible expenses from the Health Reimbursement Account administered by Compusys.

Official Plan Communications

Summary Plan Description – June 2013 - This is your benefits booklet known as the Summary Plan Description.

Summary of Benefits and Coverage (2015) - Base Plan - The Affordable Care Act (health care reform law) requires health care plans to provide members with a standardized document using consistent terminology describing the key features of the plan.

Summary of Benefits and Coverage (2015) - Medicare-Eligible Retirees - The Affordable Care Act (health care reform law) requires health care plans to provide members with a standardized document using consistent terminology describing the key features of the plan.

Summary of Benefits and Coverage (2014) - Base Plan - The Affordable Care Act (health care reform law) requires health care plans to provide members with a standardized document using consistent terminology describing the key features of the plan.

Summary of Benefits and Coverage (2014) - Medicare-Eligible Retirees - The Affordable Care Act (health care reform law) requires health care plans to provide members with a standardized document using consistent terminology describing the key features of the plan.

Summary of Benefits and Coverage (2013) - Base Plan - The Affordable Care Act (health care reform law) requires health care plans to provide members with a standardized document using consistent terminology describing the key features of the plan.

Summary of Benefits and Coverage (2013) - Medicare-Eligible Retirees - The Affordable Care Act (health care reform law) requires health care plans to provide members with a standardized document using consistent terminology describing the key features of the plan.

Summary of Material Modifications (2011) - This notice contains important Plan improvements to your Lineco Plan of benefits.

Summary Annual Report (2010) - This is the Summary Annual Report for the Plan year ending 12/31/2010.

Summary Annual Report (2009) - This is the Summary Annual Report for the Plan year ending 12/31/2009.

Summary Annual Report (2008) - This is the Summary Annual Report for the Plan year ending 12/31/2008.

Summary Annual Report (2007) - This is the Summary Annual Report for the Plan year ending 12/31/2007.

Summary Annual Report (2006) - This is the Summary Annual Report for the Plan year ending 12/31/2006.

Trust Documents

Restated Agreement and Declaration of Trust Establishing the Line Construction Benefit Fund - This is the official document that establishes this benefit trust fund.

Amendment No. 1 to the Restated Agreement and Declaration of Trust - This is the first amendment to the official document that establishes the fund.

Amendment No. 2 to the Restated Agreement and Declaration of Trust - This is the second amendment to the official document that establishes the fund.

Amendment No. 3 to the Restated Agreement and Declaration of Trust - This is the three amendment to the official document that establishes the fund.