Benefits Enrollment Form - Robert Johnson

Employee Data

Employee Name:	Robert Johnson	Employee ID:	DRV-012
Address:	1500 W Washington St, Phoenix, AZ 85003	Phone:	602-739-4718
Email:	robert.johnson@boftransport.com	Hire Date:	2025-11-15
Department:	Transportation	Job Title:	Driver

Health Plan Election

Medical Coverage Options:

Delta Health Plan — Standard

Delta Health Plan — HSA Compatible

Declined

Coverage Type	Election	Annual Employee Cost	Per Pay Period (26)
Medical	Enrolled	$3848.00	$148.00

Dental Plan Election

Dental Coverage Options:

Delta Dental Plan — Standard

Waived / No source deduction on file

Coverage Type	Election	Annual Employee Cost	Per Pay Period (26)
Dental	Waived	$0.00	$0.00

Vision Plan Election

Vision Coverage Options:

Delta Vision Plan — Standard

Waived / No source deduction on file

Coverage Type	Election	Annual Employee Cost	Per Pay Period (26)
Vision	Waived	$0.00	$22.30

Coverage Tier

Employee Only

Employee + Spouse

Employee + Child(ren)

Employee + Family

No coverage elected

Dependent Information

Dependent Name	Relationship	Date of Birth	SSN (Last 4)	Coverage
No dependent coverage elected

Supplemental Life Insurance Election

Supplemental Life — Demo Election

Waived / Not elected

Note: Life insurance elections are maintained in the Life Insurance Beneficiary Election document.

Dependent Life Insurance Election

Dependent Life — Demo Election

Waived / Not elected

Payroll Deduction Authorization

I hereby authorize Delta Advanced Trucking, Inc. to deduct elected benefits premiums from my payroll checks on a per-pay-period basis. I understand that these deductions will continue until I submit a written change request during annual open enrollment period or due to a qualifying life event.

Authorization signed for applicable deductions

Employee Signature

Robert Johnson

Employee Signature

Date: 2025-11-15

HR/Benefits Review

M. Torres

HR Representative Signature

Date: 2025-11-16

Supports payroll deduction and benefits administration.