Line Construction Benefit Fund
LINECo

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 - To be used for dependent child age 19 attending an acredited 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.