ATTENTION:
This card must be on file
with the Fund Office to
guarantee payment of your
benefits.
COMPLETE AND SUBMIT
THIS CARD:
•
•
If you want to name a
different beneficiary.
Even if you previously
submitted a card, you
can be sure your
beneficiary with the Fund
is correct by making out
a new one.
Put a postage stamp in the
indicated place and mail the
card to LINECO.
DEATH BENEFICIARY CARD
LINE CONSTRUCTION BENEFIT FUND
___________________________________________________________________________________________ ______________________________________
Name of Employee (Last) (First) (Middle Initial) SOCIAL SECURITY NUMBER
__________________________________________________________________________________________________________________________________
Home Address (Street) (City) (State) (Zip)
_____________________________ ____________________________________________ __________________________
Your Date of Birth Your Telephone Number with Area Code Local Union No.
_________________________________________________________________ _______________ _______________________________
FULL NAME OF BENEFICIARY (Last) (First) (Middle Initial) DATE OF BIRTH RELATIONSHIP TO YOU
__________________________________________________________________________________________________________________________________
Beneficiary’s Home Address (Street) (City) (State) (Zip)
___________________________________________
Beneficiary’s Social Security Number
The above-named beneficiary supersedes any and all beneficiaries previously designated. Designation of a beneficiary on this card
will be valid only if the Fund Office receives this card while you (the employee) are still living.
_______________________________ __________________________________________________________________________________________________
Date Signed Employee Signature
The Fund Office should
always have a current
mailing address FOR YOU
AND YOUR COVERED
DEPENDENTS so that you
can be sent important
information about your Plan
as well as information
about COBRA self-
payments when you or a
dependent’s coverage is
going to terminate.
If you are going to be
changing your address, or
if your address has already
changed, fill out this card
completely and sign it.
Put a postage stamp in the
indicated place and mail the
card to LINECO.
CHANGE OF ADDRESS CARD
LINE CONSTRUCTION BENEFIT FUND
This change is for: (circle one) Employee & Dependents Dependent ONLY Other (explain)_____________________________________________
If change is for a DEPENDENT ONLY, give full name of the dependent________________________________________________________________
___________________________________________________________________________________________ ______________________________________
Name of Employee (Last) (First) (Middle Initial) SOCIAL SECURITY NUMBER
________________________________________________________________
Date Address Change is Effective
__________________________________________________________________________________________________________________________________
Previous Address (Street) (City) (State) (Zip) (Telephone with Area Code)
__________________________________________________________________________________________________________________________________
New Address (Street) (City) (State) (Zip) (Telephone with Area Code)
______________________________________________________________________ __________________________________________________________
Employee Signature Date Signed
MAIL COMPLETED FORM TO:
LINE CONSTRUCTION BENEFIT FUND
821 PARKVIEW BOULEVARD
LOMBARD, IL 60148-3230
