Eagle Express Lines

Benefit Enrollment Form


Please fill out the form below as accurately as possible. You can view or download a copy of our full benefits breakdown here: Driver you will find yours in the "Insurance Information" section before any elections as certain rates may change depending on your current insurance plan, otherwise office employees may find theirs HERE

Are you applying as a Driver or a Office/Non-Driver?

Please Enter your Employee ID/Number

Basic Information


Location Information


Dependent Information


Insurance Information Full Form


Medical Insurance

After deciding which option suits you, please choose one of the monthly premiums provided.

HSA Deposits

Waiver of Health Insurance Coverage

Eagle Express Lines requires that all full-time employees participate in the company health insurance plan. These employees are only required to cover themselves; however, coverage is also available for spouses and/or dependent children at an additional cost.

This waiver is for those who have verifiable coverage under a spouse's or parent's group coverage, CHAMPUS, Tricare, Medicare as primary under TEFRA.

A waiver is granted only when the employee completes this waiver form and submits it along with proof of group health care coverage to the HR department of Eagle Express Lines.

Additional information or proof of coverage may also be required

Please type and sign your name below to waive your healthcare insurance

Dental Insurance

Vision Insurance

Voluntary Disability

Short Term Disability

Estimate your Rates for Voluntary Short Term Disability

X 60% =

X 0.075 =

Long Term Disability

Rates for Voluntary Long Term Disability

/ 12
X
=

Term Life Coverage

Rates for Voluntary Term Life

In order for your spouse and child(ren) to be covered, you must elect coverage.

Evidence of Insurability is required to increase your life insurance at Annual Open Enrollment and in excess of $200,000 in benefit.

Employee life option must be selected in order for the spouse to obtain life insurance.

Elect an amount of life insurance for your spouse:

Employee life option must be selected in order for the child(ren) to obtain life insurance.

Elect an amount of life insurance for your child(ren):

Beneficiary Election

Employee Beneficiaries:

Spouse Beneficiary:

Child Beneficiary:

Accident Insurance

Critical Illness Insurance

Employee:

Spouse:

Child(ren):

Voluntary Self Identification Information


Basic Information Full Form

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Responses will remain confidential within the Human Resources Department. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. and will be used only for the necessary information to include in our Affirmative Action Program and reporting requirements to the government. When reported, data will not identify any specific individuals. Thank you for your cooperation.

Race/Ethnic Identification

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

All persons who identify with more than one of the above five races.

Disability Information Full Form

We are asking you to complete this because we do business with the government, so we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral Palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular Dystrophy
  • Bipolar Disorder
  • Major Depression
  • Multiple Sclerosis
  • Missing/Partial Missing Limbs
  • Post-Traumatic Stress Disorder (PTSD)
  • Obsessive Compulsive Disorder (OCD)
  • Impairments requiring the use of a wheelchair
  • Intellectual Disability (Previously "Mental Retardation")

After reading, please choose an option:

Veteran Information Full Form

This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

A "disabled veteran" is one of the following:

  • A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs
  • A person who was discharged or released from active duty because of a service-connected disability.

A "recently separated veteran" means any veteran discharged or released during the most recent three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

  • Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL

Final Agreement


Please type and sign your name below to complete your benefits enrollment. This signifies that you have read and understand your benefits as an employee of Eagle Express Lines.