2 0 1 2 B E N E F I T S G U I D E - US Xpress

2012 Drivers Benefit WorksheetM O V I N G A T T H E S P E E D O F L I F EDO NOT FAX THIS FORM TO BENEFITS! This worksheet is a tool to budget your benefit premiums. Completing this worksheet does not constitutean enrollment. Please call the enrollment call center within 30 days from your hire date to enroll via telephone.DEPENDENT INFORMATIONDependent Name Relationship* Date of Birth Social Security #* Documentation will be required (such as a marriage license, civil union certificate, etc.)Please have birth dates & social security numbers available before call.MEDICAL COVERAGEEmployee Only Employee + Children Employee + Spouse* Family*Weekly RateNon-TobaccoDiscounted RateWeekly RateNon-TobaccoDiscounted RateWeekly RateNon-TobaccoDiscounted RateWeekly RateNon-TobaccoDiscounted RateWaive Coverage $0 $0 $0 $0 $0 $0 $0 $0Standard PlanPremium Plan$43/week$85/week$23/week$65/week$64/week$141/week$44/week$121/week$89/week$188/week$69/week$168/week$100/week$243/week$80/week$223/week* A Spousal Premium of $20 per week will apply if your spouse waives available benefits through their own employer.DEDUCTIONS:$________$________$________$________DENTAL COVERAGEEmployee Only FamilyWaive Coverage $0 $0Standard Plan $4.94/week $14.17/weekVISION COVERAGEEmployee Only Employee + 1 Dependent FamilyWaive Coverage $0 $0 $0Standard Plan $1.51/week $2.29/week $3.98/week$________$________DISABILITY COVERAGEWaive Coverage $0 (STD) $0 (LTD)Short Term Disability (STD) $_____________ plan ($50- $450) for employee age of ______Long Term Disability (LTD) $_____________ plan ($200- $450) for employee age of ______$________$________$________LIFE and AD&D COVERAGEBasic Life for Employee $10,000 benefit $0 (paid by company)Optional Life forEmployeeSpouseChildren$_____/month$_____________ benefit $_____________ benefit $_____________ benefit (cost TBD at enrollment)Optional AD&D forEmployee$_____________ benefitSpouse$____________ benefitChildren$_____________ benefit$_____/month(cost TBD at enrollment)TOTAL WEEKLY DEDUCTION$________$________$________When you call the enrollment number, a benefits counselor will discuss with you the following additional products and the applicable pay periodpremiums. These premiums will be deducted from your paycheck each week.