Fillable Form 2: LINECO FAMILY ENROLLMENT CARD

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Form 2: LINECO FAMILY ENROLLMENT CARD

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MC DATE
for office use only
LINECO FAMILY ENROLLMENT CARD
Complete and return to:
LINECO
Line Construction Benefit Fund
2
Lombard, IL 60148-
1-800-323-7268
Please do not use abbreviations
Employee Name Soc. Sec. #
Employee Address Phone # ()
(Street #) (City) (State) (Zip Code)
Date of Birth Sex:  M  or   F Cell Phone # () Email Address
(Circle One)
Marital Status:      Single      Married      Divorced      Separated      Legally Separated      Widowed      (Circle One)
Spouse Name Date of Birth Soc. Sec. #
***************************************Attach a CERTIFIED copy of the marriage certificate*****************************************
Spouse employer name, address & phone number: If not employed, please indicate not employed:
Dependent child / dependent child’s spouse’s employer name, address & phone #
Does the employee or listed dependent(s) have medical, dental, drug coverage with anyone other than Lineco?    YES      NO
(Circle One)
If yes, provide the name, address, phone number and copy of ID card(s) of all coverages
LIST ALL DEPENDENT CHILDREN UNDER AGE 26
Child’s Relationship to you
Full Legal Name (natural child, stepchild, or Social Security # Birthdate
other, please specify)
1.
2.
3.
4.
FOR ANY CHILD LISTED ABOVE NOT BORN OF YOUR CURRENT MARRIAGE, SEE REVERSE SIDE.
SUBMIT COPIES OF THE DIVORCE DECREE OR COPIES OF ALL COURT DOCUMENTS RELATING TO THAT CHILD.
ANY MISSING INFORMATION WILL DELAY THE PROCESSING OF CLAIMS.
*************************CALL THE FUND OFFICE FOR ALL ADDRESS AND PHONE NUMBER CHANGES***********************
COMPLETE LIFE INSURANCE INFORMATION ON THE REVERSE SIDE
Sex
Employed
Yes or No
Date Signed Signature of Employee
821 Parkview Boulevard
3230
36
PROVIDE NATURAL PARENTS’ INFORMATION FOR EACH CHILD. INFORMATION SHOULD INCLUDE PARENT’S
NAME, ADDRESS, PHONE NUMBER, BIRTHDATE, SOCIAL SECURITY NUMBER OR ID NUMBER, EMPLOYER NAME,
ADDRESS, PHONE NUMBER, AND ALL INSURANCE INFORMATION WITH A COPY OF THE MEDICAL/DENTAL CARD(S).
PROVIDE THE SAME INFORMATION FOR ALL STEP-PARENTS.
Child’s Name Relationship to Lineco Employee
Natural Mother’s Name Phone # ( )
(if not Lineco Employee)
Address
Birthdate Social Security/ID #
Employer Name
Address and Phone Number
Insurance Name
Address and Phone Number
Natural Father’s Name Phone # ( )
(If not Lineco Employee)
Address
Birthdate Social Security/ID #
Employer Name
Address Phone # ( )
Insurance Name
Address Phone # ( )
Who has physical custody of child?
*****LIFE INSURANCE BENEFICIARY INFORMATION*****
Employee Name Soc. Sec #
Name of Beneficiary
Last First Middle Initial Date of Birth Relationship
Beneficiary Address Phone # ( )
The above named beneficiary supercedes any and all beneficiaries previously designated. (Designation of a beneficiary will be valid only if the Fund Office receives this form
while you (the employee) are still living.
Date Signed Signature of Employee
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Form 2: LINECO FAMILY ENROLLMENT CARD

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Completed 13 January 2021

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