2013 XGS Office SPD.pdf - US Xpress

Xpress Global Systems
EMPLOYEE BENEFIT PLAN
SUMMARY PLAN DESCRIPTION FOR OFFICE EMPLOYEES
Introduction
This is a Summary Plan Description of the Xpress Global Systems Employee Benefit Plan (called
the "Plan" in this summary) as in effect January 1, 2013. If you have questions after reading the
Summary, please contact the employee benefits department at 1-800-670-1915. As stated in the
administrative information section of this Summary, the legal name of the Plan is the U.S. Xpress
Enterprises, Inc. Employee Benefit Plan.
This Summary cannot modify the terms of the Plan document. If there are inconsistencies
between the Summary and the Plan document, the Plan document will control. Xpress Global
Systems (called the “Company” in this Summary) has the right to terminate its participation in the
Plan and U.S. Xpress Enterprises, Inc. has the right to amend or terminate the Plan at any time.
This version of the Summary Plan Description describes benefits provided to employees who are
classified as Office Employees by the Company. For Xpress Global System employees, the Plan
is known as the Xpress Global Systems Employee Benefit Plan. There are other versions of the
Summary Plan Description for the U.S. Xpress Enterprises, Inc. Employee Benefit Plan that apply
to employees classified by the Company as Drivers and to U.S. Xpress, Total Transportation and
Arnold Transportation employees.
This group health plan believes it is a “grandfathered health plan” under the Patient Protection
and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a
grandfathered health plan can preserve certain basic health coverage that was already in effect
when that law was enacted. Being a grandfathered health plan means that your plan may not
include certain consumer protections of the Affordable Care Act that apply to other plans; for
example, the requirement for the provision of preventive health services without any cost
sharing. However, grandfathered health plans must comply with certain other consumer
protections in the Affordable Care Act; for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered health plan
status can be directed to the plan administrator at (800) 670-1915. You may also contact the
Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or
www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and
do not apply to grandfathered health plans.
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Eligibility
Any employee of the Company or an affiliated business that has adopted the Plan who is required
to work at least 33 hours per week, and who receives W-2 compensation is eligible to participate
in the Plan. A list of the affiliated business(es) that have adopted the Plan is at the end of this
document. Coverage for benefits under the Plan begins on the first day of the month following
completion of 90 days of employment. The company will honor time worked as a contractor or
temporary worker (for US Xpress) in determining the 1 st of the month following 90 days waiting
period. Employee contributions toward the cost of benefits coverage must begin to be paid one
month in advance of the date that coverage begins, with the first contribution beginning with the
first paycheck on or after the first day of the month following completion of 60 days of
employment. The Company has established a procedure regarding the refund of portions of prepaid
contributions in certain situations minus any amounts owed for taxes or administrative fees
accrued. In certain cases where an individual becomes an employee of the Company (or an
affiliated business that has adopted the Plan) as a result of the Company’s (or affiliated
business’s) acquisition of another business, the employee may be given credit for his or her
service with the acquired business for purposes of determining the effective date of the
employee’s coverage under the Plan. For medical, dental and vision benefits, you may elect to
cover your eligible dependents. Your eligible dependents are the following:
1. Your legal spouse, as determined under the law of the state in which you are a resident.
Domestic partners who are not legal spouses as described above are not eligible for medical
benefits. You will need to provide proof of spousal status.
2. Your or your legal spouse’s biological child, legally adopted child (including children placed
for adoption), step-child, eligible foster children or child for whom you or your legal spouse is
the legal guardian, provided that the child is less than 26 years old and does not have access
to his/her own employer-sponsored health coverage. If you have dependents, you’ll need to
provide proof of dependent status prior to enrolling them. Documentation may include the
appropriate marriage license, birth certificate, or court order. You may also be required to
provide documentation of their continued eligible status from time to time after they are
initially enrolled for coverage.
3. Your or your legal spouse’s child for whom a qualified medical child support order has been
issued.
4. Your or your legal spouse’s unmarried child (as described above) who is, and continues to
be, both (i) incapable of self-sustaining employment by reason of mental retardation or
physical handicap; and (ii) chiefly dependent upon you or your legal spouse for economic
support and maintenance, provided that you furnish proof of such incapacity and dependent
within 30 days of the child’s attainment of the applicable limiting age and subsequently as
may be required. In addition, the child must be a dependent enrolled in the Plan prior to
attaining the applicable limiting age.
Benefit Options
The Benefit Options under the Plan are: medical, dental & vision insurance, short and long-term
disability, AD&D, group term life, dependent care assistance benefits and medical reimbursement
benefits. For all benefits, eligibility begins on the first day of the month following completion of 90
days of full-time (at least 33 hours per week) employment.
Enrollment and Elections
In order to participate in the Plan, you must complete the enrollment process during an enrollment
period. During the enrollment process, you will select the benefits you would like to enroll in and
agree to reduce your pay for each payroll period to pay for your share of the cost of the benefit
elected. Office Employees who elect dependent care assistance and/or medical reimbursement
benefits must indicate the amount they want to contribute to their dependent care and/or medical
reimbursement benefit spending account for the Plan Year.
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The enrollment periods for the Plan are as follows:
1. Initial (New Hire) Enrollment Period: The date you first satisfy the Plan’s eligibility
requirements. This is the first time you may complete the enrollment process.
2. Regular Re-Enrollment Period: The re-enrollment period in the fall of each year. At this time,
an eligible employee or participant may add, change or revoke existing elections. New
elections will be effective at the beginning of the following Plan Year (January 1st). The Plan
Year is January 1 to December 31 of each year. If you wish to add Dependents during the
re-enrollment period, you must submit Dependent Verification.*
3. Special Enrollment Period (Change of Election): The 30 day period following an approved
Change in Status or a Change in Coverage Event. You must complete a Change in Status
form and submit Dependent Verification (if applicable) to the Company within 30 days of the
event.*
* By submitting Dependent Verification, you are acknowledging that you understand the Plan’s
eligibility requirements and certifying that the dependent(s) whom you are enrolling satisfy those
requirements. Falsification of any forms constitutes fraud or an intentional misrepresentation of
material fact and may result in the cancellation of coverage and in your being financially and
legally responsible for any claims paid for an ineligible dependent who was enrolled in the Plan.
Once you have made your election, you are not permitted to change it before the next regular
re-enrollment period, unless you have experienced a qualifying "Change in Status" or other
"Change in Cost/Coverage" event as described in the "Change in Elections" section below.
Termination of Participation
Your participation will terminate if you:
- Terminate employment;
- Retire;
- Become permanently and totally disabled; or
- Transfer to an ineligible employment category;
- Non-payment of benefit premiums within designated timeframe.
Your participation will automatically stop if the Plan is terminated.
Contributions
1. Each payroll period, your employer will reduce your taxable income by your share of the
cost of the medical, dental, vision, medical reimbursement and dependent care
assistance benefits you have elected for the Plan Year. These are pre-tax deductions.
Your contributions for AD&D and group term life, short and long-term disability benefits
are deducted from your pay on a post-tax basis. Your employer will credit the amount to a
separate account to pay for each benefit you select. Employees' share of the cost of
benefits under the Plan is set forth in the Annual Benefit Guide and may be changed by
the Company from time to time. If your share of the cost increases during a Plan Year,
either due to an increase in the cost of the benefit or a decrease in the Company's
contribution toward the cost, your contribution amount will be adjusted automatically. An
amount credited to an account for one benefit cannot be used to pay for another benefit.
2. If the reduction amount exceeds the cost of the benefit, you will not receive money back
at the end of the Plan Year.
3. If you need to go on leave for any reason, you will need to make arrangements to
continue paying premiums for your insurance benefits. Payments should be mailed to:
U.S. Xpress Direct
Attention: Benefits Department
4080 Jenkins Rd
Chattanooga, TN 37421
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4. If you are enrolled in any Allstate Workplace Division supplemental products and you
miss a monthly payment you will then be set up as a self payment through Allstate.
Medical Benefits Medical benefits under the Plan (including prescription drug benefits) are
provided on a self-insured basis by the Company, with claims paid from the general assets of the
Company and by Employees' contributions. Claim payments are paid first from employee
contributions and then, to the extent necessary, from the Company's general assets. The
Company has a contract with Blue Cross Blue Shield of Tennessee, Inc. ("BCBST") to process
claims for medical benefits under the Plan. Two coverage levels are available: standard plan and
premium plan. A detailed description of medical benefits is contained in the "Evidence of
Coverage" document prepared by BCBST, which forms part of this Summary Plan Description.
The Company has delegated to BCBST the exclusive discretionary authority to decide claims for
medical benefits under the Plan, including the right to make final determinations on appeals of
denied claims. BCBST's authority includes the right to make factual determinations with regard to
medical benefits provided under the Plan.
The Company has a contract with Medco/Express Scripts to process claims for prescription drugs
under the Plan under a self-insured arrangement. A detailed evidence of coverage booklet may
be obtained from the Human Resources department by calling the Benefits Department at (800)
670-1915. The Company has delegated to Medco/Express Scripts the exclusive discretionary
authority to decide claims for prescription drug benefits under the Plan, including the right to
make factual determinations with regard to prescription drug benefits under the Plan.
Dental Benefits Dental benefits under the Plan are provided on a fully-insured basis through an
insurance contract issued by Delta Dental Plan of Tennessee ("Delta Dental"). Premiums for
dental coverage are paid solely by the covered employee. The Company does not contribute
toward the cost of dental benefits. A detailed description of dental benefits is contained in the
benefit description document prepared by Delta Dental, which forms part of this Summary Plan
Description and is attached at the end of this Summary. Delta Dental has exclusive discretionary
authority to determine eligibility for coverage under the terms of the insurance contract, based
upon employee information provided by the Company, and to determine whether benefits are
payable under the contract and the amount of such benefits.
Vision Benefits Vision benefits under the Plan are provided on a fully-insured basis through an
insurance contract issued by Vision Service Plan (“VSP”). Premiums for vision coverage are paid
solely by the covered employee. The Company does not contribute toward the cost of vision
benefits. A description of vision benefits is contained in the benefit description document
prepared by VSP, which forms part of this Summary Plan Description and is attached at the end
of this Summary. VSP has exclusive discretionary authority to determine eligibility for coverage
under the terms of the insurance contract, based upon employee information provided by the
Company, and to determine whether any benefits are payable under the contract and the amount
of such benefits.
Long-Term Disability Benefits Long-term disability ("LTD") benefits under the Plan are
provided on a fully-insured basis through an insurance contract issued by Unum. A detailed
description of the LTD benefits is contained in the separate certificate of insurance document
prepared by Unum, which forms part of this Summary Plan Description. Premiums for LTD
coverage are paid solely by the covered employee. Employee contributions are made on an
after-tax basis. Unum has exclusive discretionary authority to determine eligibility for coverage
under the terms of the insurance contract, based upon employee information provided by the
Company, and to determine whether any benefits are payable under the contract and the amount
of such benefits. A brief summary of the LTD benefits is attached at the end of this Summary. A
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copy of the certificate of insurance coverage may be obtained from the Human Resources
department by calling the Benefits Department at (800) 670-1915.
Short-Term Disability Benefits Short-term disability ("STD") benefits under the Plan are
provided on a fully-insured basis through an insurance contract issued by Unum. A detailed
description of the STD benefits is contained in the separate certificate of insurance document
prepared by Unum, which forms part of this Summary Plan Description. The Company provides
full-time employees with $200 of weekly STD pay (eligible the first day of the month following 90
days of employment). Employees may purchase additional STD benefit from $50 per week to
$950 (maximum of up to 60% of base salary). Employee contributions are made on an after-tax
basis. Unum has exclusive discretionary authority to determine eligibility for coverage under the
terms of the insurance contract, based upon employee information provided by the Company,
and to determine whether any benefits are payable under the contract and the amount of such
benefits. As described in the certificate of insurance, benefits payable under the insurance
contract will be reduced by any benefit payable under any state statutory disability benefit plan. A
brief summary of the STD benefits is attached at the end of this Summary. A copy of the
certificate of insurance coverage may be obtained from the Human Resources department by
calling the Benefits Department at (800) 670-1915.
Accidental Death and Dismemberment Benefits Accidental death and dismemberment
("AD&D") benefits under the Plan are provided on a fully-insured basis through an insurance
contract issued by Unum. AD&D coverage is available on a voluntary basis and premiums for
AD&D coverage are paid entirely by the covered employee on an after-tax basis. A detailed
description of AD&D benefits is contained in the certificate of insurance document prepared by
Unum, which forms part of this Summary Plan Description. Unum has exclusive discretionary
authority to determine eligibility for coverage under the insurance contract, based upon employee
information provided by the Company, and to determine whether any benefits are payable under
the contract and the amount of such benefits. A copy of the certificate of insurance coverage may
be obtained from the Human Resources department by calling the Benefits Department at (800)
670-1915.
Group Term Life Benefits The Plan provides basic group term life insurance benefits as well as
voluntary supplemental group term life insurance benefits on a fully-insured basis through
contracts issued by Unum. Premiums for $10,000 of basic group term life insurance on the
employee’s life are paid entirely by the Company. Basic group life insurance is effective beginning
the first day of the month following 90 days of employment. Voluntary supplemental group term
life insurance is available on a voluntary basis and premiums are paid entirely by the covered
employee. Voluntary supplemental coverage is available for the employee as well as the
employee's dependents. A detailed description of group term life benefits is contained in the
certificate of insurance documents prepared by Unum, which form part of this Summary Plan
Description. Unum has exclusive discretionary authority to determine eligibility for coverage under
the insurance contracts, based upon employee information provided by the Company, and to
determine whether any benefits are payable under the contracts and the amount of such benefits.
Please note that voluntary supplemental coverage for the employees' spouses and dependents is
not provided through the Plan's Internal Revenue Code section 125 provisions. Employee
contributions are made on an after-tax basis. A brief summary of the basic and supplemental life
benefits is attached at the end of this Summary. A copy of the certificate of the certificate of
insurance coverage may be obtained from the Human Resources department by calling the
Benefits Department at (800) 670-1915.
Dependent Care Assistance and Medical Reimbursement Benefits Dependent care
assistance and medical reimbursement benefits are available to Office Employees. Office
Employees who elect dependent care assistance and/or medical reimbursement benefits must
specify the amount they would like to contribute for such benefits on a pre-tax basis. Enrollments
in these benefits are only allowed during open enrollment following 90 days of employment. The
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Company has a contract with PayFlex Systems USA, Inc. to process claims for dependent care
and medical reimbursement benefits. A detailed description of dependent care assistance and
medical reimbursement benefits is contained in the separate summary of dependent care and
medical reimbursement benefits document, which forms part of this Summary Plan Description
for Office Employees. A copy of the detailed summary may be obtained from the Human
Resources department by calling the Benefits Department at (800) 670-1915.
Changes in Elections
Due to Internal Revenue Service regulations, your benefit elections must remain in effect until the
beginning of the next Plan Year (the following January 1). As explained previously, each Fall,
there will be a regular re-enrollment period during which you can make elections for the next Plan
Year. The only times you are permitted to make an election change before the next Plan Year
are:
- if there is a “Change in Status” and your election change complies with the Consistency rule.
- if there is a qualified “Change in Cost / Coverage” event.
- you must complete a Change in Status/ Election form within 30 days of the event(s) and the
Company must approve the change.
Change in Status Events
1. Change in employee’s legal marital status– Including marriage, divorce, death of spouse,
legal separation, and annulment.
2. Change in number of dependents– Including birth, adoption, placement for adoption, and
death. (Must be a tax dependent)
3. Change in employment status– Employment status change of the employee, spouse, or tax
dependent. Commencement or termination of employment; strike or lockout; return from
unpaid leave of absence; promotion or demotion, change in worksite affecting benefits;
employment status change with the consequence that the individual becomes (or ceases to
be) eligible under the plan.
4. Dependent satisfies (or ceases to satisfy) eligibility requirements –An event that causes
a tax dependent to satisfy or cease to satisfy the requirements for coverage due to attainment
of age, gain or loss of student status, marriage or any similar circumstance.
5. Residence change - A change in the place of residence of an employee, spouse or tax
dependent if the change in residence affects the eligibility for coverage.
Consistency Rules
1. General consistency rule- In order to change an election due to a “Change in Status” the
election change must be on account of and correspond with a change in status event that
affects coverage eligibility of the employee, spouse or dependent under an employer’s plan.
2. Special consistency rule for loss of dependent eligibility– If the change in status is the
employee’s divorce, annulment or legal separation from a spouse, the death of a spouse or
dependent, or a dependent’s ceasing to satisfy the eligibility requirements for coverage, then
the employee can cancel accident or health insurance coverage for only the spouse or
dependent, as applicable.
3. Consistency rule for gain of coverage eligibility under another employer plan- If an
employee, spouse or dependent gains eligibility for coverage under another employer’s plan
(or qualified benefit) as a result of a change in marital status or a change in employment
status, then an employee’s election under the plan to cease or decrease coverage for that
individual under the plan corresponds with that change in status only if coverage for that
individual becomes effective or is increased under the other employer’s plan.
Change in Cost/Coverage
1. Significant Cost Increase– If the cost of a benefit package option significantly increases
during a Plan Year, you may revoke your elections and, in lieu thereof, elect to receive on a
prospective basis coverage under another benefit package option providing similar coverage.
Dropping coverage altogether is not allowed.
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2. Significant Curtailment of Coverage– If the coverage under a benefit option is significantly
curtailed or ceases during a Plan Year, affected employees may revoke their elections under
that benefit option and make a new election for coverage under another benefit package
option providing similar coverage. IRS regulations provide that coverage under an accident or
health plan is significantly curtailed “only if there is an overall reduction in coverage provided
to participants under the plan so as to constitute reduced coverage to participants generally”.
A single provider leaving a network of providers would not permit an election change.
3. Addition or Elimination of Benefit Package Option– If during a Plan Year, the Plan adds a
new coverage option (or eliminates an existing option) affected employees may elect the
newly-added option (or elect another option if an option has been eliminated) prospectively
and make a corresponding election change with respect to other benefit options providing
similar coverage.
4. Change in Coverage of Spouse or Dependent Under Other Employer’s Plan - An
employee may make a prospective election change that is on account of and corresponds
with a change made under the plan of the spouse’s, former spouse’s or dependent’s
employer if: (1) an Internal Revenue Code section 125 plan or qualified benefits plan of the
spouse’s, former spouse’s or dependent’s employer permits participants to make election
change that would be permitted under the regulations; or (2) the other employer’s plan
permits participants to make an election for a period of coverage that is different from the
period of coverage under this Plan.
5. FMLA Leaves– An employee taking leave under FMLA may revoke an existing election of
group health plan coverage and make such other election for the remaining portion of period
of coverage as may be provided for under FMLA.
6. HIPAA Special Enrollment Rights– An employee may change his/her election for group
health plan coverage under the Plan to the extent that the election change corresponds with
special enrollment rights under HIPAA.
7. COBRA– An employee may increase his/her pre-tax contributions for coverage under the
Plan if a COBRA event (or similar state law continuation coverage event) occurs with respect
to the employee, the employee’s spouse or dependent.
8. Judgment, Decree or Orders (QMCSO)- If there is a judgment, decree, or order resulting
from divorce, legal separation, annulment or change in legal custody that requires accident or
health coverage for an employee’s child or dependent foster child, then the employee may
change his/her election to add or drop coverage consistent with the order.
9. Entitlement to Medicare or Medicaid– Medicare or Medicaid entitlement or loss of
entitlement may allow an employee to make an election change.
HIPAA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes numerous
requirements on employer health plans concerning the use and disclosure of protected health
information. This portion of the Summary Plan Description is a Notice that describes the privacy
practices of the Plan and your legal rights under HIPAA regarding your protected health
information held by the Plan. Among other things, this Notice describes how your protected
health information may be used or disclosed to carry out treatment, payment, or health care
operations, or for any other purposes that are permitted or required by law. This Notice applies to
your medical (including prescription drug) benefits, dental benefits, vision benefits and medical
reimbursement benefits under the Plan.
How the Plan May Use Your Information
The Plan is permitted by law to use and disclose your personal medical information (called
“Protected Health Information”) in certain ways without your authorization:
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For treatment: So that you receive appropriate treatment and care, the Plan may disclose your
Protected Health Information to coordinate or manage your health care services. For example,
the Plan might disclose information about your prior prescriptions to a pharmacist to determine if
prior prescriptions would cause a problem with a new prescription.
For payment: To make sure that claims are paid accurately and you receive the correct benefits,
the Plan may use and disclose your Personal Health Information to determine plan eligibility and
responsibility for coverage and benefits. For example, the Plan may use your information to
confer with other health plans to resolve a coordination of benefits issue. The Plan may also use
your Personal Health Information for utilization review activities.
For health care operations: To ensure quality and efficient plan operations, the Plan may use
your Personal Health Information in several ways, including plan administration, quality
assessment and improvement, and vendor review. Your information could be used, for example,
to assist in the evaluation of a vendor who supports the Plan. The Plan may contact you to
provide information about treatment alternatives or other health-related benefits and services
available under the Plan.
To Business Associates: The Plan may contract with individuals or entities known as Business
Associates to perform various functions involving Protected Health Information on the Plan’s
behalf or to provide certain types of services for the Plan.
As Required by Law: The Plan may disclose your Protected Health Information when required
to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety: The Plan may use and disclose your Protected
Health Information when necessary to prevent a serious threat to your health and safety, or the
health and safety of the public or another person.
Organ and Tissue Donation: If you are an organ donor, the Plan may release your Protected
Health Information to organizations that handle organ procurement or organ, eye, or tissue
transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation
and transplantation.
Military and Veterans: If you are a member of the armed forces, the Plan may release your
Protected Health Information as required by military command authorities.
Workers' Compensation: The Plan may release your Protected Health Information for workers'
compensation or similar programs.
Public Health Risks: The Plan may disclose your Protected Health Information for public health
actions, such as to prevent or control disease or to report abuse, neglect or domestic violence.
Health Oversight Activities: The Plan may disclose your Protected Health Information to a
health oversight agency for activities authorized by law (for example, audits, investigations,
inspections, and licensure).
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, the Plan may disclose your
Protected Health Information in response to a court or administrative order, or in response to a
subpoena, discovery request, or other lawful process by someone else involved in the dispute,
but only if efforts have been made to tell you about the request or to obtain an order protecting
the information requested.
Law Enforcement: The Plan may disclose your Protected Health Information if asked to do so by
a law enforcement official (for example, to identify a suspect or missing person).
Coroners, Medical Examiners and Funeral Directors: The Plan may release your Protected
Health Information to a coroner or medical examiner.
National Security and Intelligence Activities: The Plan may release your Protected Health
Information to authorized federal officials for intelligence, counterintelligence, and other national
security activities authorized by law.
Inmates: If you are an inmate of a correctional institution or are in the custody of a law
enforcement official, the Plan may disclose your Protected Health Information to the correctional
institution or law enforcement official if necessary for the institution to provide you with health
care, to protect your health and safety or the health and safety of others, for the safety and
security of the correctional institution.
Research: The Plan may disclose your Protected Health Information to researchers when the
individual identifiers have been removed or when an institutional review board or privacy board
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has reviewed the research proposal and established protocols to ensure the privacy of the
requested information and approves the research.
Plan Sponsor: The Plan may disclose your Protected Health Information to U.S. Xpress
Enterprises, Inc. (the plan sponsor) in connection with these activities and other plan
administration activities. Employees in the following positions may have access to your protected
health information for plan administration purposes: Benefits Department; Privacy Officer; Privacy
Manager; Employee Relations Department; Vice President and Legal Counsel; and Vice
President of Human Resources. If you are covered under an insured health plan, the insurer also
may disclose Protected Health Information to the plan sponsor in connection with payment,
treatment or health care operations.
Other Purposes Permitted or Required by Law: The Plan may disclose your Protected Health
Information for other purposes required by law, provided that the use or disclosure is limited to
the relevant requirements of such law.
In Special Situations: The Plan may disclose your Protected Health Information to a family
member, relative, close personal friend, or any other person whom you identify, when that
information is directly relevant to the person's involvement with your care or payment related to
your care. The Plan also may use your Protected Health Information to notify a family member,
your personal representative, another person responsible for your care, or certain disaster relief
agencies of your location, general condition, or death. If you are incapacitated, there is an
emergency, or you otherwise do not have the opportunity to agree to or object to this use or
disclosure, the Plan will do what in the administrator's judgment is in your best interest regarding
such disclosure and will disclose only information that is directly relevant to the person's
involvement with your health care. The Plan will make other uses and disclosures only after you
authorize them in writing. You may revoke your authorization in writing at any time.
Your Rights Regarding Protected Health Information
You have the right to:
• Inspect and copy your Protected Health Information
• If the Plan uses electronic health records, you have the right to obtain an electronic copy
of the Protected Health Information in the record and, if you so choose, the Protected
Health Information will be transmitted directly to an entity or person you specify, provided
your directive is clear, conspicuous and specific
• Request that your Protected Health Information be amended or corrected if inaccurate
• Receive an accounting of certain disclosures of your information made by the Plan; you
are not entitled to an accounting of several types of disclosures, including, but not limited
to:
― Disclosures made for payment, treatment or health care operations
― Disclosures made to you
― Disclosures made to friends or family in your presence or because of an emergency
― Disclosures for national security purposes― Disclosures you authorized in writing
― Disclosures made before April 14, 2003
― Disclosures incidental to otherwise permissible disclosures.
• Receive a paper copy of this notice, even if you agreed to receive it electronically.
Right to Request Restrictions
You may ask the Plan to restrict how it uses and discloses your Protected Health Information as it
carries out payment, treatment, or health care operations. You may also ask the Plan to restrict
disclosures to your family members, relatives, friends, or other persons you identify who are
involved in your care or payment for your care. However, the Plan is not required to agree to
these requests.
Right to Request Confidential Communications
You may request to receive your Protected Health Information by alternative means or at an
alternative location if you reasonably believe that other disclosure could pose a danger to you.
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For example, you may only want to have information sent by mail or to an address other than
your home.
For more information about exercising these rights, contact the office below.
Right to Be Notified of a Breach
You have the right to be notified in the event that the Plan or a Business Associate of the Plan
discovers a breach involving your unsecured protected health information.
Complaints
If you believe that your privacy rights have been violated, you may file a written complaint without
fear of reprisal. Direct your complaint to the office listed below under “Contacting Us” or to the
Secretary of Health and Human Services, Hubert H. Humphrey Building, 200 Independence
Avenue, SW, Washington, DC 20201.
About this Notice
The Plan is required by law to maintain the privacy of Protected Health Information and to provide
individuals with notice of its legal duties and privacy practices with respect to Protected Health
Information. The Plan is required to abide by the terms of this Notice. The Plan reserves the
right to change the terms of this Notice and to make the new notice provisions effective for all
Protected Health Information it maintains. If this Notice is changed, you will receive a new notice
via mail.
Contacting Us
You may exercise the rights described in this notice by contacting the U.S. Xpress office identified
below, which will provide you with additional information. The contact is:
Amanda Thompson
Sr. Director, Compensation & Benefits
Human Resources Department
(800) 251-6291 x 3491
NOTICE OF RIGHTS TO CONTINUE GROUP HEALTH COVERAGE
This section of the Summary Plan Description is your notice of continuation coverage rights under
the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"). COBRA continuation
coverage can become available to you and to your spouse and dependent children, if they are
covered under the Plan when you would otherwise lose your group health coverage. Under the
Plan, COBRA continuation coverage rights apply to medical (including prescription drug), vision and
dental benefits and also apply on a limited basis to medical reimbursement benefits. COBRA
continuation coverage is a continuation of Plan coverage when coverage would otherwise end
because of a life event known as a "qualifying event." Specific qualifying events are listed later in this
notice. COBRA continuation coverage must be offered to each person who is a "qualified
beneficiary." A qualified beneficiary is someone who will lose coverage under the Plan because of a
qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and
dependent children of employees may be qualified beneficiaries. Under the Plan, qualified
beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you are an employee covered under the Plan, you have a right to choose this continuation
coverage if you lose your group health coverage because of a reduction in your hours of employment
or the termination of your employment (for reasons other than gross misconduct on your part). If you
are the spouse of an employee covered by the Plan, you have the right to choose continuation
coverage for yourself if you lose group health coverage under the Plan for any of the following four
reasons:
1) The death of your spouse;
2) A termination of your spouse's employment (for reasons other than gross misconduct) or a
reduction in your spouse's hours of employment;
3) Divorce or legal separation from your spouse; or
10

4) Your spouse becomes entitled to Medicare.
In the case of a dependent child of an employee covered by the Plan, he or she has the right to
continuation coverage if group health coverage under the Plan is lost for any of the following five
reasons:
1) The death of a parent;
2) A termination of a parent's employment (for reasons other than gross misconduct) or reduction in
a parent’s hours of employment;
3) Parent’s divorce or legal separation;
4) A parent becomes entitled to Medicare; or
5) The dependent child ceases to be a "dependent child" under the U.S. Xpress Inc. Employee
Benefit Plan.
Furthermore, a child born to, or placed for adoption with, the covered employee during the period of
continuation coverage may also become covered as a qualified beneficiary.
Under the law, the employee or a family member has the responsibility to inform the Plan
Administrator of a divorce, legal separation, or a child losing dependent status under the Plan within
60 days of the date of the event or the date in which coverage would end under the Plan because of
the event, whichever is later. The Company has the responsibility to notify the Plan Administrator of
the employee's death, termination, and reduction in hours of employment or Medicare entitlement.
When the Plan Administrator is notified that one of these events has happened, the Plan
Administrator will in turn notify you that you have the right to choose continuation coverage. Under
the law, you have at least 60 days from the date you would lose coverage because of one of the
events described above, or the date notice of your election rights is sent to you, whichever is later, to
inform the Plan Administrator that you want continuation coverage. If you do not choose continuation
coverage, your group health insurance coverage will end. Also, if you do not become re-employed
within 63 days of your termination of employment, and you have not chosen continuation coverage,
you may lose prior coverage credit toward pre-existing condition limitation periods when you next
become insured.
If you choose continuation coverage, the Company is required to give you coverage which, as of the
time coverage is being provided, is similar to the coverage provided under the plan to similarly
situated employees or family members. The law requires that you be afforded the opportunity to
maintain continuation coverage for 36 months unless you lost group health coverage because of a
termination of employment or reduction in hours. In that case, the required continuation coverage
period is 18 months. This18 months may be extended to 36 months if other events (such as a death,
divorce, legal separation, or Medicare entitlement) occur during that 18-month period. If a second
qualifying event occurs, you must make sure that the Plan Administrator is notified of the second
qualifying event within 60 days of the second qualifying event. Continuation coverage for medical
reimbursement benefits is only available through the end of the Plan Year in which the qualifying
event occurs.
The 18 months may be extended to 29 months for an individual, and his/her qualified dependents, if
the individual is determined to be disabled (for Social Security disability purposes) at the time of the
qualifying event or at any time during the first 60 days of continuation coverage, and the Plan
Administrator is notified of that determination within 60 days of the date of the determination and
before the end of the 18-month period. The affected individual must also notify the Plan Administrator
within 30 days of any final determination that the individual is no longer disabled. In no event will
continuation coverage last beyond 3 years from the date of the event that originally made a qualified
beneficiary eligible to elect coverage.
However, the law also provides that your continuation coverage may be terminated before the end of
the maximum period for any of the following five reasons:
11

(1) The Company no longer provides group health coverage to any of its employees
(2) You do not pay the premium for your continuation coverage on time
(3) You become covered under another group health plan after the date of your COBRA
election, unless that plan contains any exclusions or limitations with respect to any preexisting
conditions you or your covered dependents may have
(4) You become entitled to Medicare after the date of your COBRA election
(5) You extended coverage for up to 29 months due to your disability and there has been a
final determination that you are no longer disabled.
You do not have to show that you are insurable to choose continuation coverage.
In order to protect your family's rights, you should keep the Plan Administrator informed
of any changes in the addresses of family members. You should also keep a copy, for your
records, of any notices you send to the Plan Administrator.
Maternity and Newborn Coverage
Your Plan provides maternity and newborn infant coverage. Federal law generally prohibits this
Plan from restricting benefits for any hospital length of stay in connection with childbirth for the
mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96
hours following a cesarean section. Federal law also generally prohibits the Plan from requiring
that a Provider obtain authorization to prescribe a length of stay in excess of the above periods.
Please refer to the Covered Services section of the BlueCross BlueShield of Tennessee
Evidence of Coverage document for details.
Qualified Medical Child Support Order
In accordance with section 609(a) of ERISA, the Plan will provide health benefit coverage to a
child of a participant in accordance with the terms of any medical child support order that the Plan
Administrator determines to be a "qualified medical child support order." A qualified medical child
support order is a judgment, decree or order issued by a court, which provides for child support or
health benefit coverage relating to benefits under the Plan and which meets certain requirements
regarding substance and form. Medical child support orders should be submitted to the Plan
Administrator, who will promptly notify the involved individuals of its receipt of the order and of the
Plan's procedure for determining whether the order is a qualified order. You may request a copy
of the Plan's procedure for determining whether an order is a qualified medical child support order
from the Human Resources Department.
Certificate of Creditable Coverage
A certificate of creditable coverage is a document that reports the period of time that you and/or a
dependent have had medical benefits coverage under the Plan without a significant break in
coverage. This information may be helpful if you or a dependent become covered under a group
health plan other than the Plan and that other group health plan contains a preexisting condition
limitation. Under Federal law, your coverage or your dependent’s coverage under this Plan may
reduce or eliminate the application of the other plan’s preexisting condition limitation.
A certificate of creditable coverage will be provided automatically when your coverage or your
dependent’s coverage under the Plan terminates. You or your dependent also have the right to
request a certificate of creditable coverage from the Plan at any time, as long as your request is
made within 24 months after your coverage or your dependent’s coverage under the Plan
terminates. Requests should be directed to the Human Resources Benefits Department at1-800-
670-1915.
Medicaid-Eligible Individuals
In determining whether an individual is eligible for health benefit coverage and is making benefit
payments, the Plan will not take into account the fact that an individual is eligible for or is covered
by Medicaid.
12

In addition, the Plan will make benefit payments in accordance with any assignment of rights
made by or on behalf of an individual as required by a state Medicaid program and in accordance
with any state law which provides that the state has acquired rights to payment with respect to a
participant.
Mastectomy Benefit Coverage
Under Federal law, group health plans, insurance companies, and health maintenance
organizations (HMOs) that provide coverage for medical and surgical benefits for mastectomy
must also provide coverage for reconstructive surgery in a manner determined in consultation
with the attending physician and the patient.
Required coverage includes reconstruction of the breast on which the mastectomy was
performed, surgery and reconstruction of the other breast to produce a symmetrical appearance,
and prostheses and treatment of physical complications at all stages of the mastectomy, including
lymphedemas. These benefits are subject to the normal deductible and coinsurance provisions
that apply to other benefits under your coverage.
Statement of Rights
As a participant in the Plan, you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants be
entitled to:
Receive Information About Your Plan and Benefits.
Examine, without charge, at the Plan Administrator's office and at other specific locations all
documents governing the Plan including insurance contracts and a copy of the latest annual
report (Form 5500) filed by the Plan with the U.S. Department of Labor and available at the Public
Disclosure Room of the Pension and Welfare Benefit Administration.
Obtain upon written request to the Plan Administrator, copies of documents governing the
operation of the Plan, including insurance contracts and copies of the latest annual report (Form
5500) and updated summary plan description. The Plan Administrator may make a reasonable
charge for the copies.
Receive a summary of the Plan's annual financial report. The Plan Administrator is required by
law to furnish you with a copy of this summary annual report.
Continue Group Health Plan Coverage.
Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage
under the Plan as a result of a qualifying event. You or your dependents may have to pay for
such coverage. Review this summary plan description and the documents governing the Plan on
the rules governing your COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your
group health plan, if you have creditable coverage from another plan. You should be provided a
certificate of creditable coverage, free of charge, from your group health plan or health insurance
issuer when you lose coverage under the plan, when you become entitled to elect COBRA
continuation coverage, when your COBRA continuation coverage ceases, if you request it before
losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of
creditable coverage, you may subject to a preexisting condition exclusion for 12 months (18
months for late enrollees) after your enrollment date in your coverage.
Prudent Actions by Plan Fiduciaries.
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your Plan,
called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other
Plan participants and beneficiaries. No one, including your employer or any other person, may
13

fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare
benefit or exercising your rights under ERISA.
Enforce Your Rights.
If your claim for a welfare benefit is denied or ignored, you have a right to know why this was
done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you
request a copy of Plan documents or the latest annual report from the Plan and do not receive
them within 30 days, you may file suit in a Federal court. In such a case, the court may require
the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the
materials, unless the materials were not sent because of reasons beyond the control of the Plan
Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you
may file suit in a state or federal court, provided that you have exhausted your administrative
appeal rights. In addition, if you disagree with the Plan’s decision or lack thereof concerning the
qualified status of a medical child support order, you may file suit in Federal court. If it should
happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may
file suit in a Federal court. The court will decide who should pay court costs and legal fees. If
you are successful the court may order the person you have sued to pay these costs and fees. If
you lose, the court may order you to pay these costs and fees; for example, if it finds your claim is
frivolous.
Assistance With Your Questions.
If you have any questions about your Plan, you should contact the Plan Administrator. If you
have any questions about this statement or about your rights under ERISA, or if you need
assistance in obtaining documents from the Plan Administrator, you should contact the nearest
Area Office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in
your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits
Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington,
D.C. 20210. You may also obtain certain publications about your rights and responsibilities under
ERISA by calling the publications hotline of the Employee Benefits Security Administration.
Claims Procedures
Specific claim procedures for medical benefits are set forth in the medical Evidence of Coverage
document. Specific claim procedures for long-term disability benefits, accidental death and
dismemberment benefits and group term life insurance benefits are set forth in the certificates of
insurance that describe those benefits. Specific claim procedures for dependent care assistance
benefits and medical reimbursement benefits are set forth in the separate summary of those
benefits. The following claim procedures apply to dental and vision benefit claims. References to
the insurance carrier refer to Delta Dental Plan of Tennessee for dental benefits and VSP for
vision benefits.
If you are required to obtain pre-approval from your insurance carrier as a prerequisite to
obtaining a benefit, you should follow the pre-approval procedures established by the insurance
carrier.
If you contact your insurance carrier to obtain pre-approval but you fail to follow the pre-approval
procedure for filing a pre-service claim, the insurance carrier is required to notify you of this failure
and the proper procedure for filing the pre-service claim. A pre-service claim is a benefit claim
that requires some form of pre-approval by the insurance carrier. The notice is required to be
provided to you as soon as possible but not later than 5 days after the failure, or, in the case of an
urgent care claim (see below), within 24 hours of the failure. The notice may be given to you
orally, unless you request a written notice.
14

You may designate a representative to act on your behalf in pursuing a benefit claim or appealing
a denial of a benefit claim by contacting your insurance carrier. Even if you have not formally
designated a representative, your physician or licensed health care professional may act on your
behalf as your authorized representative if the benefit claim is an urgent care claim (see below).
The period within which the insurance carrier is required to decide your claim depends upon the
type of claim being made. There are generally three types of claims that can be made under the
Plan – a pre-service claim, an urgent care claim, and a post-service claim.
Pre-Service Claim – A pre-service claim is a claim for a benefit which requires some form of preapproval
by the insurance carrier. The insurance carrier must decide a pre-service claim within
15 days. This 15 day period may be extended for up to an additional 15 days if the insurance
company determines the extension is necessary for reasons beyond its control. The insurance
carrier is required to notify a claimant in writing if there is an extension.
Urgent Care Claim – An urgent care claim is a pre-service claim where application of the normal
period for deciding pre-service claims could jeopardize the life, health or ability to regain
maximum function of the claimant, or would subject the claimant to severe pain that cannot be
adequately managed without the care or treatment that is being claimed. The insurance carrier is
required to decide an urgent care claim within 72 hours.
Post-Service Claim – A post-service claim is any claim that is not a pre-service claim. It would
include a claim in which the medical procedure has already occurred and the claimant is seeking
payment of it or reimbursement for it. The insurance carrier is required to decide a post-service
claim within 30 days. This 30 day period may be extended for up to an additional 15 days if the
insurance carrier determines the extension is necessary for reasons beyond its control. The
insurance carrier is required to notify a claimant in writing if there is an extension.
In addition, some special rules apply where the insurance carrier has already approved an
ongoing course of treatment over a period of time or number of treatments. First, if the insurance
carrier reduces or terminates coverage for the course of treatment before it otherwise would have
ended, that reduction or termination is a benefit denial. The insurance carrier must notify the
claimant sufficiently in advance of the reduction or termination to allow the claimant to appeal the
decision (see Appealing a Claim below) and to obtain a decision on the appeal. Second, if the
claimant requests an extension of the course of treatment at least 24 hours before the course of
treatment ends and it is an urgent care situation (see Urgent Care Claim above), the insurance
carrier must notify the claimant within 24 hours of its decision on the extension request.
If your claim is allowed, the insurance carrier will notify you who has been paid and the amount
that has been paid, or will be paid, in the case of a pre-service claim. If your claim is denied in
whole or in part, you will receive a written notice which must include the following information:
1. The specific reason or reasons for the denial of all or any portion of the claim.
2. The specific provisions of the coverage certificate, subscriber contract, the Plan and any
other document, on which the denial is based. If the decision to deny benefits is based,
in whole or in part, on a specific internal rule, guideline, protocol or similar criteria, either
a copy of the document will be provided to you or you may request a copy of such
document from the insurance carrier at no charge. If the decision to deny benefits is
based, in whole or in part, on an exclusion or limitation that the treatment is experimental
or investigational, or that the treatment is not medically necessary, either an explanation
that applies the appropriate terms to your medical circumstances, and which details the
scientific or clinical judgment that led to the decision to deny benefits will be provided to
you or you may request such an explanation from the insurance carrier at no charge.
15

3. A description of any additional material or information necessary for you to complete the
claim, and an explanation as to why such information or material is necessary.
4. Information as to how you may submit the claim for review and the applicable time limits.
5. A statement regarding your right to bring a civil suit under federal law should your appeal
be denied.
In the case of an urgent care claim, the notice of denial may be provided to you orally within the
72 hour period, so long as a written notice is provided within 3 days thereafter.
You may appeal a claim denial by following the appeal procedure explained below.
Appealing a Claim
If you do not agree with the denial or partial denial of your claim or if you have questions
concerning your claim, you are encouraged to contact the insurance carrier handling your claim.
If you wish to appeal a claim denial, you may need to complete a form provided and required by
your insurance carrier to file your appeal. In your appeal, you must state that you are requesting
an official review of your claim and the reason(s) why you do not agree with the denial or partial
denial of your claims and any additional information pertinent to the claim. You should contact the
insurance carrier to bring an appeal.
Except in the case of urgent care claims, the insurance carrier need not consider any telephone
inquiry as a request for an official review of a denied claim. However, if the claim which is denied
is an urgent care claim, you can request an expedited appeal by calling the insurance carrier
handling your claim.
If you want to appeal a denied claim, the insurance carrier must allow you at least 180 days after
you receive notice of a denial or partial denial to file the appeal. During the 180 days (or any
longer period the insurance carrier may allow), you or your representative may review and obtain
from the insurance carrier copies of all documents, records and information relating to your claim.
If you wish, you or your representative may submit written issues, comments and additional
justification as to why the claim should be allowed. The insurance carrier is required to provide
you with the name of each medical or vocational expert whose advice was obtained in connection
with your denied claim, regardless of whether the advice was relied upon.
When the insurance carrier reviews a denied claim, it may not afford any deference to the initial
decision. The review will be conducted by an individual, committee or department identified in
your subscriber contract or coverage certificate. If the benefit denial is based in whole or in part
on a medical judgment, such as whether the procedure is experimental or is not medically
necessary, the person reviewing the claim at the insurance carrier is required to consult with a
health care professional who has appropriate training and experience in the particular field of
medicine relating to your claim. This health care professional will be someone who was not
consulted on the initial claim denial.
The review of a claim denial is required to be done by the insurance carrier within the following
time frames:
Pre-Service Claim If the denied claim was a pre-service claim (other than an urgent care claim)
the insurance carrier is required to decide your appeal within 30 days.
Urgent Care Claim If the denied claim was an urgent care claim, the insurance carrier is
required to decide your appeal within 72 hours.
16

Post-Service Claim If the denied claim was a post-service claim, the insurance carrier is
required to decide your appeal within 60 days.
The insurance carrier is required to provide you with a written notice of the determination on
review. If the denial of your claim is upheld (in whole or in part) the notice is required to include
the following information:
1. The specific reason or reasons for the adverse determination.
2. The specific provisions of the subscriber contract, certificate of coverage, the Plan and
any other document on which the adverse determination is based.
3. A statement that you may obtain, upon request and free of charge, reasonable access to
and copies of all documents, records and other information relevant to your claim for
benefits. If any internal rule, guideline, protocol or similar guideline was relied upon in
making the adverse determination, the insurance carrier must either provide it to you with
the written notice or provide you with a copy of it free of charge upon request. If the
adverse determination is based on medical necessity, experimental treatment or a similar
exclusion, the insurance carrier must either provide an explanation of the scientific or
clinical judgment for the adverse determination to you with the written notice, or provide it
to you free of charge upon request.
4. If the insurance carrier has any voluntary appeal procedures, information regarding those
procedures.
Should you have any questions regarding the claims procedure, please contact the Human
Resources Benefits Department.
_____________________________________________________________________________
Name of Plan:
Plan Sponsor:
Plan Administrator:
Address:
U.S. XPRESS Enterprises, Inc. Employee Benefit Plan
U.S. XPRESS Enterprises, Inc.
U.S. XPRESS Enterprises, Inc.
4080 Jenkins Road
Chattanooga, TN 37421
Telephone: 423-510-3000
Employer ID: 62-1378182
Plan #: 501
Agent for Service of Legal Process: Vice President & General Counsel
Address:
4080 Jenkins Road
Chattanooga, TN 37421
Service of Legal Process may be made on the Plan Administrator.
Plan Year:
Calendar Year
17

Type of Plan: Welfare plan providing health (hospitalization, physician visits, prescription drugs,
outpatient services and preventative services), dental, vision, long-term disability, AD&D and
group term life, dependent care assistance benefits and medical reimbursement benefits. The
Plan is also an Internal Revenue Code section 125 plan and an Internal Revenue Code section
129 plan.
Funding: Except for medical benefits, benefits are fully insured. Medical benefits are self-insured
with claims paid from the general assets of the Company and employee contributions. Premiums
for fully insured benefits are paid in whole or part by the Company out of its general assets and in
part by the Employee’s pre-tax or post-tax payroll deductions. The Plan Administrator provides a
schedule of the applicable premiums during the initial and subsequent annual enrollment periods
and on request for each of the component benefit programs, as applicable.
Claims Administrators and Insurance Carriers:
1. Blue Cross Blue Shield of Tennessee, Inc.
1 Cameron Hill Circle
Chattanooga, TN 37402-2555
(800) 565-9140
2. PayFlex Systems USA, Inc.
P.O. Box 3039
Omaha, NE 68103-3039
(800) 284-4885
3. Delta Dental Plan of Tennessee
240 Venture Circle
Nashville, TN 37228
(800) 223-3104
4. Medco/Express Scripts.
N 19 W24130 Riverwood Drive
Waukesha, WI 53188
800-721-3501
5. VSP
3091 Governors Lake Drive, Suite 240
Norcross, GA 30071
(800) 877-7195
6. Unum
1 Fountain Square
Chattanooga, TN 37402
(877) 281-1746
7. Allstate Workplace Division
1776 American Heritage Life Drive
Jacksonville, FL 32224
1-800-521-3535
18

Please contact the Benefits Department for a complete copy of the Evidence of Medical Coverage.
19

Xpress Global Systems Employee Benefit Plan
Brief Summary of Basic Life, Supplemental Life & AD&D,
Long-Term Disability and Short-Term Disability Benefits for Office Employees
BASIC LIFE
Xpress Global Systems provides a benefit of a $10,000 the first of the month following 90
days of full-time employment. The amount of Basic Life, Supplement Life and AD&D will be
reduced to 65% of the pre-age amount at age 65 and shall be further reduced to 50% of the
pre-age amount at age 70 and terminates at retirement.
SUPPLEMENTAL LIFE & AD&D
• In addition to the Life insurance coverage provided for you by Xpress Global Systems, you
have the option of purchasing additional amounts of Life Insurance for yourself and your
family. Upon enrollment in the new hire process, the effective date is the first of the month
following 90 days of full-time employment. If enrolling during the annual benefits enrollment
process, the effective date of coverage is January 1 following the annual enrollment period.
The amount of Basic Life, Supplement Life and AD&D will be reduced to 65% of the pre-age
amount at age 65 and shall be further reduced to 50% of the pre-age amount at age 70 and
terminates at retirement.
• You will be allowed to purchase coverage in increments of $10,000 up to the lesser of
$500,000 or 5 times your salary on yourself. You may also purchase coverage on your
Spouse in increments of $5,000 up to the lesser of $250,000 (proof of good health required
for amounts over $50,000) or the amount of life insurance on yourself. You are also eligible to
purchase coverage for your children in the increments of $2,500 up to a maximum of $10,000
for dependent child(ren). Please note that the coverage amount from live birth up to age six
months is $2,500. Children may be covered up to age 19 or to age 26 if full-time student.
• Accidental Death & Dismemberment (AD&D) insurance is available in $10,000 units up to
$500,000 or 5 times your salary whichever is less on you and in $5,000 units for your
spouse. AD&D is available for your dependent child(ren) in $2,500 units up to $10,000.
• If you decline coverage during the new hire process, and later decide you want coverage, you
will be required to complete an Evidence of Insurability (EOI) form subject to approval by
Unum.
• Please refer to the Xpress Benefits Guide for pricing on these benefits.
ADDITIONAL FEATURES INCLUDED
• Worldwide Emergency Travel
• Accelerated Death Benefit of 75% of Benefit Amount up to $500,000
• Waiver of Premium in Event of Total Disability
• Ability to port and/or convert supplementary life insurance plans within 30 days of leaving
employment
• Critical Illness Benefit
• If the insured qualifies for benefits in accordance with the Waiver of Premium in the Event of
Total Disability provision because he/she has been diagnosed by a physician as totally
disabled due to any of the following conditions or procedures (as defined in the policy);
1) Life threatening cancer,
2) Heart attack,
3) Kidney failure,
4) Receipt of a major organ transplant, or
5) Stroke
28

OFFICE SHORT TERM DISABILITY
• Upon enrollment in the new hire process, the effective date is the first of the month following
90 days of full-time employment. If enrolling during the annual benefits enrollment process,
the effective date of coverage is January 1 following the annual enrollment period provided
an EOI form is completed by the employee and approved by Unum.
• Benefits payable for Physician covered Non-Occupational disabilities
• Benefits begin on the 15 th day of disability for either Accident or Sickness
• Xpress Global Systems provides a company-paid $200 weekly benefit for Office employees.
• Employees can purchase coverage in increments of $50 to a weekly maximum of $950 not to
exceed 60% of weekly earnings
• The benefit is based on the average gross income for the 12 weeks immediately preceding
the date of disability.
• The benefit will be payable as long as you are disabled for benefits up to 13 weeks.
• Maternity is covered the same as any other disability.
• If you decline coverage during the new hire process and later decide you want coverage, you
will be required to complete an Evidence of Insurability (EOI) form subject to approval by
Unum.
For exact cost for this plan, please refer to information contained in the Xpress Benefits Guide.
OFFICE LONG TERM DISABILITY
• Upon enrollment in the new hire process, the effective date is the first of the month following
90 days of full-time employment. If enrolling during the annual benefits enrollment process,
the effective date of coverage is January 1 following the annual enrollment period provided
an EOI form is completed by the employee and approved by Unum.
• Provides benefits for covered disabilities (Occupational and Non-Occupational)
• Eligible class: Office employees
• Benefit is available in increments of $50 starting from $200 to $1,150 of weekly benefit not to
exceed 60% of your covered monthly earnings to a maximum monthly benefit of $4,984
($8,307 of covered monthly earnings)
• The benefit is based on the average gross income for the 12 weeks immediately preceding
the date of disability.
• Benefit is payable after 90 day elimination period is satisfied by a covered disability. This
elimination period begins first day of disability and includes any time covered by Short-Term
Disability.
• 6/12/24 Pre-Existing condition limitation
• Benefit is payable, as long as you are disabled, up to five years.
• Partial & Residual coverage included (total disability is never required)
29

• If you decline coverage during the new hire process and later decide you want coverage, you
will be required to complete an Evidence of Insurability (EOI) form subject to approval by
Unum.
• The lifetime cumulative maximum benefit period for all disabilities due to mental
illness is 24 months. Only 24 months of benefits will be paid even if the disabilities:
- are not continuous; and/or
- are not related.
However, Unum will send you payments beyond the 24 month period if you meet
one of these conditions:
1. If you are confined to a hospital or institution at the end of the 24 month period,
Unum will continue to send you payments during your confinement.
If you are still disabled when you are discharged, Unum will send you payments
for a recovery period of up to 90 days.
If you become reconfined at any time during the recovery period and remain
confined for at least 14 days in a row, Unum will send payments during that
additional confinement and for one additional recovery period up to 90 more
days.
2. If you are not confined to a hospital or institution but become confined for a
period of at least 14 days within 90 days after the 24 month period for which you
have received payments, Unum will send payments during the length of the
confinement.
Under no circumstances will Unum pay beyond the maximum period of payment as
Indicated in the BENEFITS AT A GLANCE section of your policy.
Unum will not apply the mental illness limitation to dementia if it is a result of:
- stroke;
- trauma;
- viral infection;
- Alzheimer's disease; or
- other conditions not listed which are not usually treated by a mental health
provider or other qualified provider using psychotherapy, psychotropic drugs, or
other similar methods of treatment.
For exact cost for this plan, please refer to information contained in the Xpress Benefits Guide.
THIS IS NOT A CONTRACT. This summary is not intended as a complete description of Unum’s
insurance coverage. The controlling provisions are provided in the policy, and this summary does
not modify those provisions or the insurance in any way.
Coverage provided by Unum under Policy Number 294727-002.
FULL DESCRIPTIONS IN CERTIFICATE OF INSURANCE
This summary of benefits is not a complete description of the Basic Life, Supplemental Life &
AD&D, Long-Term Disability and Short-Term Disability benefits under the Plan. Detailed
descriptions are contained in the certificates of insurance for each benefit, which may be obtained
from the Human Resources department by calling the Benefits Department at (800) 670-1915.
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