Member Forms
New Member Online Enrollment - If you are a new member, click here to complete your enrollment online.
Existing Members Enrollment Changes - Use this form to make changes to your family status (adding newborns, adding spouses, divorce situations, etc.)
Authorization to Disclose Health Information (PHI) - Authorization to disclose your health information to another person or organization.
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.
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 - Member/Dependent approval for any provider to release all information related to any illness or injury requested by LINECO.
Member Medical Claim Form - Use this form when filing claims for medical reimbursement when your out of network provider will not bill insurance.
Continuity of Care - Please complete this form if your network provider has left the network and you are currently undergoing treatment for a serious medical issue.
Health Reimbursement Account (HRA)
HRA Reimbursement Request Form - The most efficient way to submit HRA Claims is via the online portal or mobile app. Please click here for that option. If you are unable to submit the claims electronically, this form may be completed by the LINECO HRA member to request reimbursement for eligible expenses from the Health Reimbursement Account.
Weekly Income/Disability
Initial Application Weekly Income - This form should be used by an employee for their initial application for the LINECO Weekly Income benefit. The employee is responsible for getting this form completed in full and returned to LINECO.
Continuing Application Weekly Income - This form should only be used if an employee has already been approved for the LINECO weekly income benefit AND the employee is still considered disabled and would like to extend those benefits. The employee is responsible for having their treating physician complete this form.