Fillable Form must be completed in full before payment (LINECO)

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Form must be completed in full before payment (LINECO)

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Weekly Income Benet Form — Initial Application For Benets
1 WI-04/17
Form must be completed in full before payment is considered.
Return to: Line Construction Benet Fund, 821 Parkview Boulevard, Lombard, IL 60148-3230, Or fax to: 630-916-6847.
Section 1 – Participant’s Information (please print)
Participant’s Identication Number (LCB) Participant’s Full Name Date of Birth
Participant’s Complete Address
Name of Employer
Date of Accident Date of Last Day Worked Return to Work Date Where did accident occur?
o Home o Work o Auto o Other
How did accident occur? Please explain below:
Is your disability in any way work related? o Yes o No If yes, please explain below:
If you have been denied by Workers’ Compensation, attach a copy of the denial and a notarized statement of whether or not you intend to appeal.
Authorization: I hereby authorize any doctor, hospital, or insurance company to furnish and disclose all known facts.
Signature of Participant Participant’s Phone Number Date
Section 2 – Employer’s Statement (please print) COMPLETE AFTER LAST DATE WORKED
What was the employee’s
last day worked?
What date did the employee
return to work?
Is absence work related?
o Yes o No
Is light duty restricted work available? o Yes o No Has a claim been led for Worker’s Compensation related to this injury? o Yes o No
Was employee on Layoff? o Yes o No Due to: o No Work o Disability
Date of Layoff
Authorized Employer Representative Name Authorized Employer Signature
Employer’s Name
Employer’s Address
Employer’s Phone Number Employer’s Fax Number Date Form Completed
2 WI-04/17
Form must be completed in full before payment is considered.
Return to: Line Construction Benet Fund, 821 Parkview Boulevard, Lombard, IL 60148-3230, Or fax to: 630-916-6847.
Section 3 – Physician’s Statement (please print)
Participant’s Identication Number (LCB) Participant’s Full Name Date of Birth
Participant’s Complete Address
Is condition due to:
o Illness o Injury o Work Related
Was patient hospitalized?
o Yes, indicate date: ___________________
o No
Referred to a Specialist? o Yes o No
Date Disability Began 1
st
Treatment Date After Last Work Day Date of next appointment?
Diagnosis
Goals/Treatment plan
Restrictions?
Additional Comments
Actual Return to Work Date Estimated Return to Work Date (this must be completed)
Physician’s Signature Print Physician’s Name + Degree
Physician’s Phone Number Physician’s Fax Number Date Form Completed
Weekly Income Benet Form — Initial Application For Benets
PROCEDURES TO FILE FOR WEEKLY INCOME BENEFITS
Complete the enclosed Claim Forms to apply for Weekly Income Benefits. All
sections of the Claim Forms must be completed in order for LINECO to determine
if benefits are available. See pages 71 and 72 in the 2017 Summary Plan
Description (SPD) or visit the LINECO website at www.lineco.org for specific
qualifying rules for the Weekly Income Benefit.
There are also specific rules governing substance abuse disabilities. There is
limited benefits available. See Pages 71 and 72 in the SPD.
COMPLETING CLAIM FORM:
Section 1: Must be completed by the employee
Section 2: Must be completed by your employer’s HR Department after your last date worked
Section 3: Must be completed by your treating physician
It is your responsibility to ensure that ALL sections of the Weekly Income Forms are completed
SUBMITTING CLAIM FORM:
Once the Claim Forms are completed, you can either mail or fax claim to:
Mail: LINECO
821 Parkview Blvd
Lombard, IL 60148 – 3230
Fax: (630) 916-6847
PHYSICIAN UPDATES:
If approved for Weekly Income Benefit, you may be asked to submit a Weekly Income Continuation Form to
LINECO with updates from your physician. Please return the form promptly to avoid delay in processing your
payments.
What happens when I exhaust Weekly Income Benefits??
You may qualify for continued eligibility in the LINECO plan of benefits from the eligibility due to
disability provision or will be offered the opportunity to continue in the plan via COBRA.
Questions about the Weekly Income Benefit can be directed to the Weekly
Income / Disability department at LINECO at 1-800-323-7268. Once approved
for benefits, you may track your weekly income payments on our secure
member portal at www.lineco.org.
HOW DO I FILE
FOR WEEKLY
INCOME
BENEFITS?
Questions ??
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Completed 15 January 2021

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