Driver Info

Roadies Logo

3906 THAMES CT

BAKERSFIELD CA 93313

PH: 661-214-8880, FAX: 661-412-8320

By signing this document, I agree with all the terms and conditions of ROADIES INC which are:

Miles will be calculated by dispatch software via PRO MILER.

Roadies has right to dismiss from job if duties are not performed properly.

ROADIES INC will hold $300.00 for every driver as a deposit.

Pickup and delivery are to be done by driver unless dispatch approve you not to do so.

If dispatch tell you to take specific route, you must obey that.

Driver must update following in Dispatch APP

f dispatch tell you to take specific route, you must obey that.

Check in and check out time at shipper

Seal number

Check in and check out time at receiver

Upload BOL and lumper receipt

Not reported lumper receipt at time of delivery will be deducted from driver pay.

No night pays available on missed appointment unless there is equipment breakdown.

Layover will be considered only after 14 hours.

Logbook issues will be resolved only at office hours.

Making on time delivery and pick up is driver’s responsibility for any given job. Late fees or re-schedule fees will be deducted from your pay.

After any over the road incident or speeding ticket, Roadies Inc will take disciplinary action and driver will receive corrective training. If driver is at fault for any accident and damage to company equipment, insurance deductible or full cost of repair will be charged to driver.

Refusal to assigned job will be considered as sick call.

Securing the load and maintain required temperature is driver’s responsibility. If failed to do so will result in charge back to driver for the loss or cost of restacking and bringing that load back to receiver or shipper.

ROADIES INC have dash cam in trucks, I am not allowed to block cameras in any circumstances due to safety reasons.

There will be $500 fine for lost or missing POD (proof of delivery).

If you need any day off, you should request it one week prior to that day.

You are agreeing to all the policies and procedures provide in policy manual by Roadies Inc.

Driver must give 2 weeks’ NOTICE before leaving job.

Probation period is 3 months, if the driver quit his job within 3 months of hiring, drug test and application fee will be deducted from the pay.

You are agreeing to all the policies and procedures provide in policy manual by Roadies Inc.

Subject to deduction from pay, if any of the following is not done by driver:

Pre-trip and Post-trip DVIR

If we found any fault in SAFE DVIR

Bill of Lading with all the paperwork received from receiver uploaded with clear pictures and lumper receipts.

Logbook violation for over-driving.

Print Name:
Signature:
Date:

ACKNOWLEDGMENT & AGREEMENT

I have received my copy of Roadies’ Employee Handbook. I have read and understand each of the policies in the Handbook, and agree to abide by the Company’s policies.

Specifically, I understand and agree that my employment is at-will and may be terminated by me or the Company with or without advance notice and with or without “cause.” I understand this to be the final expression as to the nature of my employment relationship. I understand and agree this sets forth the entire agreement between the parties and fully supersedes any and all prior agreements or understandings, written or oral, between the parties pertaining to the subject matter hereof.

I understand and agree that my at-will status can be changed only by a written employment agreement signed by the CEO of the Company and me that expressly provides for a relationship other than at-will employment.

I also understand and agree that, except for the at-will relationship the Company may change any policy or practice and/or my hours, wages, working conditions, job assignments, position title, compensation rates and benefits in its sole discretion.

Employee Name:
Employee Signature:
Date:

AT-WILL EMPLOYMENT AGREEMENT

Employment at Roadies Inc., a California corporation (“Roadies”) is employment at will. Employment at-will means that the employment relationship can be terminated at the will of either Roadies Inc. or you at any time, with or without cause, and with or without advance notice.

Specifically, I understand and agree that my employment is at-will and may be terminated by me or Roadies with or without advance notice and with or without “cause.” I understand this Agreement to be the final expression as to the nature of my employment relationship. I understand and agree this sets forth the entire agreement between the parties and fully supersedes any and all prior agreements or understandings, written or oral, between the parties pertaining to the subject matter hereof.

I understand and agree that my at-will status can be changed only by a written employment agreement signed by Avninder Singh, the CEO of Roadies and me, that expressly provides for a relationship other than at-will employment.

I also understand and agree that, except for the at-will relationship, Roadies may change any policy or practice and/or my hours, wages, working conditions, job assignments, position title, compensation rates and benefits in its sole discretion.

Employee Name:
Employee Signature:
Date:

ANTI-HARASSMENT, DISCRIMINATION, AND RETALIATION POLICY

Roadies Inc., a California corporation, (the “Company”) is committed to providing a work environment free of harassment, discrimination, and/or retaliation. Company policy prohibits harassment, discrimination disrespectful or unprofessional conduct based on sex (including pregnancy, childbirth, breastfeeding or related medical conditions), race (including natural hair style), religion (including religious dress and grooming practices), color, gender (including gender identity and gender expression), national origin or ancestry, physical or mental disability, medical condition, genetic information, marital status, registered domestic partner status, age, sexual orientation or any other basis protected by federal, state, local law, ordinance or regulation. The Company’s policy also prohibits harassment, discrimination, disrespectful or unprofessional conduct based on the perception that anyone has any of the listed characteristics, or is associated with a person who has or is perceived as having any of the listed characteristics.

The Company’s anti-harassment, discrimination, and retaliation policy applies to all persons involved in the operation of the Company and prohibits harassment, discrimination, retaliation, and disrespectful or unprofessional conduct by any employee of the Company, including supervisors and managers, as well as any applicants, vendors, customers, independent contractors, interns and any other third persons.

Prohibited harassment (including sexual harassment), disrespectful or unprofessional conduct includes, but is not limited to, the following behavior:

Verbal conduct such as epithets, derogatory jokes or comments, slurs or unwanted sexual advances, invitations or comments;

Visual displays such as derogatory and/or sexually-oriented posters, photography, cartoons, drawings or gestures;

Physical conduct including assault, unwanted touching, intentionally blocking normal movement or interfering with work because of sex, race or any other protected basis;

Threats and demands to submit to sexual requests as a condition of continued employment, or to avoid some other loss and offers of employment benefits in return for sexual favors;

Retaliation for reporting or threatening to report harassment;

Communication via electronic media of any type that includes any conduct that is prohibited by state and/or federal law, or by Company policy; and,

Bullying or abusive conduct: This is defined as conduct of an employer or employee in the workplace, with malice, that a reasonable person would find hostile, offensive, and unrelated to an employer's legitimate business interests. Abusive conduct may include repeated infliction of verbal abuse, such as the use of derogatory remarks, insults, and epithets, verbal or physical conduct, cyber bullying via social media websites or elsewhere on the internet, that a reasonable person would find threatening, intimidating, or humiliating, or the gratuitous sabotage or undermining of a person's work performance. A single act shall not constitute abusive conduct, unless especially severe and egregious.

If you believe that you have been the subject of harassment, discrimination, or retaliation, you should bring your complaint, either orally or in writing to Avninder Singh, the CEO, or Rajdeep Singh, the Office Manager, or Dalbir Singh, Director of Operations as soon as possible after the incident. It would be best to communicate your complaint in writing, but as noted, this is not mandatory. Supervisors are required to refer all complaints involving harassment, discrimination, or retaliation to the CEO, the Office Manager, or the Director of Administration. You also should be aware that the Federal Equal Employment Opportunity Commission (“EEOC”) and the California Department of Fair Employment and Housing (“DFEH”) investigate and prosecute complaints of unlawful harassment, discrimination, and retaliation with respect to employment. If you think you have been harassed, discriminated against, or that you have been retaliated against for resisting or making a complaint, you may file a complaint with the appropriate agency. For additional information, you may access the internet at http://www.eeoc.gov/ for the EEOC and/or http://www.dfeh.ca.gov/ for the DFEH.

Once a complaint has been lodged with the Company, the Company will conduct a fair, timely, and thorough investigation by an impartial and qualified person(s) that provides all parties appropriate due process and will reach a reasonable conclusion based on the evidence collected. As part of this investigation, you will be asked to provide details of the incident or incidents, names of individuals involved and names of any witnesses. The investigator shall keep documentation and track the reasonable progress of the investigation. To the extent possible, the Company will maintain confidentiality of complaints and the facts received before, during, and after the complaint process. However, the Company cannot guarantee complete confidentiality.

If after the investigation the Company determines that a violation of this policy or other misconduct has occurred, appropriate remedial actions and resolutions will be taken. The Company will conclude the investigation as quickly as possible. At the conclusion of the investigation, a Company representative will advise all parties concerned of the results of the investigation. The Company will not retaliate against you for filing a complaint or participating in a workplace investigation and will not tolerate or permit retaliation by management, employees or co-workers.

The Company encourages all employees to report any incidents of harassment, discrimination, or other prohibited conduct forbidden by this policy immediately so that complaints can be quickly and fairly resolved.

ACKNOWLEDGMENT OF RECEIPT

I have received a copy of the above regarding the Company’s anti-harassment, discrimination, and retaliation policy. I understand and agree that it is my responsibility to read and follow this policy. I understand and will conduct myself in a manner consistent with the Company's anti harassment, discrimination, and retaliation policy. I understand the Company's complaint and reporting procedure.

I understand and agree that nothing in this policy creates or is intended to create a promise or representation of continued employment and that employment with the Company is employment at-will. I understand that except for employment at-will status, any and all policies or practices can be changed at any time by the Company. By signing below, I acknowledge that I have read and received the Company’s anti-harassment, discrimination, and retaliation policy as described above.

Employee’s Printed Name:
Employee’s Signature:
Date:

As required by the California New Parent Leave Act (S.B. 63), is issuing this notice of employment reinstatement guarantee as follows:

Employee name:
Date parental leave commenced::
Expected return to work date:
Position:
Location:

guarantees reinstatement to the same or equivalent position upon conclusion of the employee's parental leave.

Employer Signature:
Date:

Form W-4

Department of the Treasury Internal Revenue Service

Employee’s Withholding Certificate

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

Give Form W-4 to your employer.

Your withholding is subject to review by the IRS.

OMB No. 1545-0074

2020

Step 1: Enter Personal Information

(a) First name and middle initial

Last name

(b) Social security number

Address

City or town, state, and ZIP code

▶ Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

Single or Married filing separately

Married filing jointly (or Qualifying widow(er))

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . ▶

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

IMultiply the number of qualifying children under age 17 by $2,000 ▶ $

Multiply the number of other dependents by $500 . . . . ▶ $

Add the amounts above and enter the total here . . . . . . . .

3

$

Step 4 (optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . .

4a

$

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . .

4b

$

(c) Extra withholding. Enter any additional tax you want withheld each pay period .

4c

$

Step 5: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete

▶

▶

Employee’s signature (This form is not valid unless you sign it.)

Date

Employers Only

Employer’s name and address

First date of employment

Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Cat. No. 10220Q

Form W-4 (2020)

Form W-4 (2020)

Page 2

General Instructions

Future Developments

For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose of Form

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505.

Exemption from withholding. You may claim exemption from withholding for 2020 if you meet both of the following conditions: you had no federal income tax liability in 2019 and you expect to have no federal income tax liability in 2020. You had no federal income tax liability in 2019 if (1) your total tax on line 16 on your 2019 Form 1040 or 1040-SR is zero (or less than the sum of lines 18a, 18b, and 18c), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2020 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1a, 1b, and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2021.

Your privacy. If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy.

As an alternative to the estimator: if you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c). If this is the only job in your household, you may instead check the box in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of dollars over the year).

When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you:

1. Expect to work only part of the year;

2. Have dividend or capital gain income, or are subject to additional taxes, such as the additional Medicare tax;

3. Have self-employment income (see below); or

4. Prefer the most accurate withholding for multiple job situations.

Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.

Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific Instructions

Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.

Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.

Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.

if you (and your spouse) have a total of only two jobs, you may instead check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

Img

Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

Step 3. Step 3 of Form W-4 provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

Step 4 (optional).

Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2020 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.

Form W-4 (2020)

Page 3

Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

Img

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

1

Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the “Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3 . . . . . .

1

$

2

Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries and enter that value on line 2a . . . . . . . . . . . . . .

a

Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries and enter that value on line 2a . . . .

2a

$

b

Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b . . . . .

2b

$

c

Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . .

2c

$

3

Enter the number of pay periods per year for the highest paying job. For example, if that job pays weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . .

3

$

4

Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional amount you want withheld) . . . . . . . . . .

4

$

Step 4(b)—Deductions Worksheet (Keep for your records.)

Img

1

Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income . . . . .

1

$

2

Enter:

• $24,800 if you’re married filing jointly or qualifying widow(er)

• $18,650 if you’re head of household

• $12,400 if you’re single or married filing separately

. . . . . .

2

$

3

If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . ..

3

$

4

Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information . .

4

$

5

Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . .

5

$

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

Form W-4 (2020)

Page 4

Married Filing Jointly or Qualifying Widow(er)

Married Filing Jointly or Qualifying Widow(er)

Lower Paying Job Annual Taxable Wage & Salary

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$0

220

850

$220

1,220

1,900

$850

1,900

2,730

$900

2,100

2,930

$1,020

2,220

3,050

$1,020

2,220

3,050

$1,020

2,220

3,050

$1,020

2,220

3,240

$1,020

2,410

4,240

$1,210

3,410

5,240

$1,870

4,070

5,900

$1,870

4,070

5,900

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

900

1,020

1,020

2,100

2,220

2,220

2,930

3,050

3,050

3,130

3,250

3,250

3,250

3,370

3,570

3,250

3,570

4,570

3,440

4,570

5,570

4,440

5,570

6,570

5,440

6,570

7,570

6,440

7,570

8,570

7,100

8,220

8,220

7,100

8,220

9,220

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 99,999

1,020

1,020

1,060

2,220

2,220

3,260

3,260

3,240

5,090

3,440

4,440

6,290

4,570

5,570

7,420

5,570

6,570

8,420

6,570

7,570

9,420

7,570

8,570

10,420

8,570

9,570

11,420

9,570

10,570

12,420

10,220

11,220

13,260

10,220

11,240

13,460

$100,000 - 149,999

$150,000 - 239,999

$240,000 - 259,999

1,870

2,040

2,040

4,070

4,440

4,440

5,900

6,470

6,470

7,100

7,870

7,870

8,220

9,190

9,190

9,320

10,390

10,390

10,520

11,590

11,590

11,720

12,790

12,790

12,920

13,990

13,990

14,120

15,190

15,520

14,980

16,050

17,170

15,180

16,250

18,170

$260,000 - 279,999

$280,000 - 299,999

$300,000 - 319,999

2,040

2,040

2,040

4,440

4,440

4,440

6,470

6,470

6,470

7,870

7,870

8,200

9,190

9,190

10,320

10,390

10,720

12,320

11,590

12,720

14,320

13,120

14,720

16,320

15,120

16,720

18,320

17,120

18,720

20,320

18,770

20,370

21,970

19,770

21,370

22,970

$320,000 - 364,999

$365,000 - 524,999

$525,000 and over

2,720

2,970

3,140

5,920

6,470

6,840

8,750

9,600

10,170

10,950

12,100

12,870

12,870

12,870

15,500

15,070

16,830

18,000

17,070

19,130

20,500

19,070

21,430

23,000

21,290

23,730

25,500

23,590

26,030

28,000

25,540

27,980

30,150

30,150

29,280

31,650

Single or Married Filing Separately

Higher Paying Job Annual Taxable Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$460

940

1,020

$940

1,530

1,610

$1,020

1,610

2,130

$1,020

2,060

3,130

$1,470

3,060

4,130

$1,870

3,460

4,540

$1,870

3,460

4,540

$1,870

3,460

4,720

$1,870

3,640

4,920

$2,040

3,830

5,110

$2,040

3,830

5,110

$2,040

3,830

5,110

$30,000 - 39,999

$40,000 - 59,999

$60,000 - 79,999

1,020

1,870

1,870

2,060

3,460

3,460

3,130

4,540

4,690

4,130

5,540

5,890

5,130

6,690

7,090

5,540

7,290

7,690

5,720

7,490

7,890

5,920

7,690

8,090

6,120

7,890

8,290

6,310

8,080

8,480

6,310

8,080

9,260

9,260

8,080

10,060

$80,000 - 99,999

$100,000 - 124,999

$125,000 - 149,999

2,020

2,040

2,040

2,040

3,830

3,830

5,090

5,110

5,110

5,110

6,310

7,030

7,490

7,510

9,030

8,090

8,430

10,430

8,290

9,430

11,430

8,490

10,430

12,580

9,470

11,430

13,880

10,460

12,420

15,170

11,260

13,520

16,270

12,060

14,620

17,370

$150,000 - 174,999

$175,000 - 199,999

$200,000 - 249,999

2,360

2,720

2,970

4,950

5,310

5,860

7,030

7,540

8,240

9,030

9,840

10,540

11,030

12,140

12,840

12,730

13,840

14,540

14,030

15,140

15,840

15,330

16,440

17,140

16,630

17,740

17,740

17,920

19,030

19,730

19,020

20,130

20,830

20,120

21,230

21,230

$250,000 - 399,999

$400,000 - 449,999

$450,000 and over

2,970

2,970

3,140

5,860

5,860

6,230

8,240

8,240

8,810

10,540

10,540

11,310

12,840

12,840

13,810

14,540

14,540

15,710

15,840

15,840

17,210

17,140

17,140

18,710

18,440

18,450

20,210

19,730

19,940

21,700

20,830

21,240

23,000

21,930

22,540

24,300

Head of Household

Higher Paying Job Annual Taxable Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$0

830

930

$830

1,920

2,130

$930

2,130

2,350

$1,020

2,220

2,430

$1,020

2,220

2,900

$1,020

2,680

3,900

$1,480

3,680

4,900

$1,870

4,070

5,340

$1,870

4,130

5,540

$1,930

4,330

5,740

$2,040

4,440

5,850

$2,040

4,440

5,850

$30,000 - 39,999

$30,000 - 39,999

$60,000 - 79,999

1,020

1,020

1,870

2,220

2,220

4,070

4,070

3,750

5,310

2,980

4,830

6,600

3,980

5,860

7,800

4,980

7,060

9,000

6,040

8,260

10,200

6,630

8,850

10,780

6,830

9,050

10,980

7,030

9,250

11,180

7,140

9,360

11,580

7,140

9,360

12,380

$80,000 - 99,999

$100,000 - 124,999

$125,000 - 149,999

1,900

2,040

2,040

4,300

4,440

4,440

5,710

5,850

5,850

7,000

7,140

7,360

8,200

8,340

9,360

9,400

9,540

11,360

10,600

11,360

13,360

11,180

12,750

14,750

12,75

13,750

16,010

12,670

14,750

17,310

13,580

15,770

18,520

14,380

16,870

19,620

$150,000 - 174,999

$175,000 - 199,999

$200,000 - 249,999

2,040

2,720

2,970

5,060

5,920

6,470

7,280

8,130

8,990

9,360

10,480

11,370

11,360

12,780

13,670

13,480

15,080

15,970

15,780

17,380

18,270

17,460

19,070

19,960

18,760

20,370

21,260

20,060

21,670

21,670

21,270

22,880

23,770

23,770

23,980

24,870

$250,000 - 349,999

$350,000 - 449,999

$450,000 and over

2,970

2,970

3,140

6,470

6,470

6,840

8,990

8,990

9,560

11,370

11,370

12,140

13,670

13,670

14,640

15,970

15,970

17,140

18,270

18,270

19,640

19,960

19,960

21,530

21,260

21,260

23,030

22,560

22,560

24,530

23,770

23,900

25,940

24,870

25,200

27,240

Roadies Logo

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS
Form I-9

OMB No. 1615-0047
Expires 08/31/2019
► START HERE : Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: : It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
Date of Birth (mm/dd/yyyy) U.S. Social Security Number
- -
Employee's E-mail Address Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States(See instructions)
3. A lawful permanent resident (Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field. (See instructions)
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number
1. Alien Registration Number/USCIS Number:
OR
2. Form I-94 Admission Number:
OR
3. Foreign Passport Number:
  Country of Issuance:
QR Code - Section 1
Do Not Write In This Space
Signature of Employee Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator Today's Date (mm/dd/yyyy)
Last Name(Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town State ZIP Code
Roadies Logo

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS
Form I-9

OMB No. 1615-0047
Expires 08/31/2019
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Employee Info from Section 1 Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status
List A
Identity and Employment Authorization 		OR List B
Identity 		AND List C
Employment Authorization
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Additional Information
QR Code - Sections 2 & 3 Do Not Write In This Spac
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions
Employer's Business or Organization Address (Street Number and Name)
Today's Date (mm/dd/yyyy)
Title of Employer or Authorized Representative (mm/dd/yyyy)
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town
State
Zip Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) B. Date of Rehire (if applicable)
Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
Document Title Document Number Expiration Date (if any) (mm/dd/yyyy
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED

Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.

LIST A
Documents that Establish Both Identity and Employment Authorization

OR

LIST B
Documents that Establish Identity

AND

LIST C
Documents that Establish Employment Authorization

1.

U.S. Passport or U.S. Passport Card

2

Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

3.

Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4.

Employment Authorization Document that contains a photograph (Form I-766)

5.

For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

a. Foreign passport; and

b. Form I-94 or Form I-94A that has the following:

(1) The same name as the passport; and

(2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form

5.

Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

1.

Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

2.

ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

3.

School ID card with a photograph

4.

Voter's registration card

5.

U.S. Military card or draft record

6.

Military dependent's ID card

7.

U.S. Coast Guard Merchant Mariner Card

8.

Native American tribal document

9.

Driver's license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

10.

School record or report card

11.

Clinic, doctor, or hospital record

12.

Day-care or nursery school record

1.

A Social Security Account Number card, unless the card includes one of the following restrictions:

(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

2.

Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3.

Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4.

Native American tribal document

5.

U.S. Citizen ID Card (Form I-197)

6.

Identification Card for Use of Resident Citizen in the United States (Form I-179)

7.

Employment authorization document issued by the Department of Homeland Security

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

NOTICE TO EMPLOYEE

Labor Code section 2810.5

EMPLOYEE

Employee Name:
Start Date:

EMPLOYER

Legal Name of Hiring Employer:

Is hiring employer a staffing agency/business (e.g., Temporary Services Agency; Employee Leasing

Company; or Professional Employer Organization [PEO])? Yes No

Other Names Hiring Employer is "doing business as" (if applicable):

Physical Address of Hiring Employer’s Main Office:

Hiring Employer’s Mailing Address (if different than above):

Hiring Employer’s Telephone Number:

If the hiring employer is a staffing agency/business (above box checked "Yes"), the following is the other entity for whom this employee will perform work:

Name:

Physical Address of Main Office:

Mailing Address:

Telephone Number:

WAGE INFORMATION

Rate(s) of Pay:

Overtime Rate(s) of Pay:

Rate by (check box): Hour Shift Day Week Salary Piece rate Commission

Hour Other (provide specifics):

Does a written agreement exist providing the rate(s) of pay? (check box) Yes No

If yes, are all rate(s) of pay and bases thereof contained in that written agreement? Yes No

Allowances, if any, claimed as part of minimum wage (including meal or lodging allowances):

(If the employee has signed the acknowledgment of receipt below, it does not constitute a “voluntary written agreement” as required under the law between the employer and employee in order to credit any meals or lodging against the minimum wage. Any such voluntary written agreement must be evidenced by a separate document.)

Regular Payday:

WORKER’S COMPENSATION

Insurance Carrier’s Name:

Address:

Telephone Number:

Policy No.:

Self-Insured (Labor Code 3700) and Certificate Number for Consent to Self-Insure:

PAID SICK LEAVE

Unless exempt, the employee identified on this notice is entitled to minimum requirements for paid sick leave under state law which provides that an employee:

a. May accrue paid sick leave and may request and use up to 3 days or 24 hours of accrued paid sick leave per year;

b. May not be terminated or retaliated against for using or requesting the use of accrued paid sick leave; and

c. Has the right to file a complaint against an employer who retaliates or discriminates against an employee for

1. requesting or using accrued sick days;

2. attempting to exercise the right to use accrued paid sick days;

3. filing a complaint or alleging a violation of Article 1.5 section 245 et seq. of the California Labor Code;

4. cooperating in an investigation or prosecution of an alleged violation of this Article or opposing any policy or practice or act that is prohibited by Article 1.5 section 245 et seq. of the California Labor Code.

The following applies to the employee identified on this notice: (Check one box)

1. Accrues paid sick leave only pursuant to the minimum requirements stated in Labor Code §245 et seq. with no other employer policy providing additional or different terms for accrual and use of paid sick leave.

2. Accrues paid sick leave pursuant to the employer’s policy which satisfies or exceeds the accrual, carryover, and use requirements of Labor Code §246.

3. Employer provides no less than 24 hours (or 3 days) of paid sick leave at the beginning of each 12-month period.

4. The employee is exempt from paid sick leave protection by Labor Code §245.5. (State exemption and specific subsection for exemption):

PAID SICK LEAVE

(Optional)

(PRINT NAME of Employer representative)

(PRINT NAME of Employee)

(PRINT NAME of Employer representative)

(PRINT NAME of Employee)

(Date)

(Date)

The employee’s signature on this notice merely constitutes acknowledgement of receipt

Labor Code section 2810.5(b) requires that the employer notify you in writing of any changes to the information set forth in this Notice within seven calendar days after the time of the changes, unless one of the following applies: (a) All changes are reflected on a timely wage statement furnished in accordance with Labor Code section 226; (b) Notice of all changes is provided in another writing required by law within seven days of the changes.

DRIVER COMPENSATION AGREEMENT

This Driver Compensation Agreement (hereinafter, the “Agreement”) is made by and between Roadies Inc. a California corporation, (hereinafter, the “Employer or “Roadies Inc.”) and (hereinafter, “Employee”), an individual. Employer and Employee are collectively referred to herein as “parties.” This Agreement is effective as of

Recitals

WHEREAS, Employer is a commercial motor carrier in the business of interstate trucking;

WHEREAS, Employee is a licensed driver of commercial trucks;

WHEREAS, Employer desires to [obtain the service of] / [continue to employ] Employee, and Employee desires to provide services to Employer in accordance with the terms, conditions and covenants set forth in this Agreement. Accordingly, in consideration of the mutual promises, covenants, and undertakings set forth herein, the parties hereto hereby agree as follow.

Relationship of the Parties.

1. Roadies Inc. hereby agrees to employ Employee, and Employee hereby agrees to provide services to Employer in the position of commercial truck driver upon the terms and conditions hereinafter set forth herein.

2. The parties mutually agree that the employment relationship is at-will, meaning that either party may terminate the employment relationship without advance notice, and with or without cause. No other provision of this Agreement and/or any policy or procedure of Employer, written or otherwise, may modify this at-will employment relationship.

3. Employee shall be employed as a commercial vehicle driver. Unless otherwise agreed to in writing signed by both parties, no modification or change of Employee’s position, responsibilities, duties, compensation, benefits and/or job description shall otherwise modify, change or revoke any provision of this Agreement.

4. Employee agrees to perform to the best of Employee’s ability and experience, all of the duties, responsibilities and obligations either expressly or implicitly required by the terms of this Agreement at all times loyally and conscientiously. Employee’s primary duties and responsibilities include loading, transporting, delivering and/or unloading freight (hereinafter, “Services”). Employer may modify these duties and responsibilities in its sole discretion from time to time. Employee shall comply with the federal Hours of Service requirements.

5. Employee shall be bound by all the policies, rules, and regulations of Employer now in force, including but not limited to those set forth in the Employer’s Employee Handbook, and by all such other policies, rules and regulations as may be hereafter implemented and called to Employee’s notice, and will faithfully observe an abide by the same. No such policy, rule or regulation shall alter, modify, or revoke Employee’s status as an at-will employee or any other provision of this Agreement.

Compensation

In no event will the compensation due to any employee be less than the applicable minimum wage for each hour worked daily. Compensation shall be paid as follows:

6. Mileage-Based Compensation. Employee will be paid a piece rate of __ per mile driven.

s7. Rest and Recovery Time. Employee shall be paid for rest and recovery periods at the rate required by California law (Labor Code §226.2(a)(3)). The rate of compensation for required rest and recovery periods shall be an average hourly rate determined by dividing the total compensation for the workweek, exclusive of compensation for rest and recovery periods and overtime premiums (if applicable), by the total hours worked during the workweek, exclusive of rest and recovery periods. In no event shall the rate for rest and recovery periods ever be less than the applicable minimum wage.

8. Non-Productive Time. Employee shall be paid $___ for non-driving time during which they are on duty (if any). Non-productive time is considered any time when an employee is subject to Company’s control, exclusive of rest and recovery periods, that is not directly related to driving the vehicle. Non-productive time includes but is not limited to time spent:

• Fueling vehicle;

• Loading/unloading vehicles

• Dealing with vehicle breakdowns;

• Waiting for freight or vehicle to arrive;

• Attending meetings, including dispatch meetings; and

• Mandatory training

Employee is not compensated for off-duty time, including without limitation, time in sleeper berth.

9. Timekeeping. Employer shall provide timecards to Employee separate from and in addition to the electronic logs that Employee is required to keep. It is critical that Employee document driving time, rest and recovery time, on-duty, non-driving time, and the time the driver goes off-duty so that Employer can properly compensate Employee pursuant to California law.

Property of the Employer.

10. Upon termination of Employee’s employment, Employee agrees to immediately return to Employer all property of Employer in as good condition as when received by Employee (normal wear and tear excepted) including, but not limited to, vehicles, cargo, equipment, and similar items relating to the business of the Employer.

Miscellaneous.

11. Governing Law and Jurisdiction. This Agreement shall be governed and construed in accordance with the laws of the State of California except for its choice of law provisions. The parties agree that should a conflict arise as to any interpretation of this Agreement, or as to the applicability as to any clause contained herein, or as to the enforceability of the Agreement, the Superior Court of California, County of Alameda retains jurisdiction thereto in order to make such a determination.

12. Modification. Except as provided in paragraph 4, above, any modification to any term of this Agreement must be in writing and signed by the parties. Informal Resolution. The parties agree that they shall attempt to resolve any dispute between them related to this Agreement informally, by direct, good faith negotiation, prior to initiating any formal proceedings.

13. Complete Agreement. This Agreement replaces and supersedes any previous document or agreement(s) between Employee and Employer with respect to compensation and the terms contained herein.

14.Complete Agreement. This Agreement replaces and supersedes any previous document or agreement(s) between Employee and Employer with respect to compensation and the terms contained herein.

s15. Mutual Drafting of Agreement. This Agreement shall be construed and interpreted fairly in accordance with the plain meaning of its terms, and there shall be no presumption or inference against the party drafting this Agreement in construing or interpreting the provisions hereof.

16. Advice of Counsel and Mutually Voluntary Agreement. Each party further acknowledges and agrees that they have had the opportunity to consult with, or have consulted with, attorneys of their own choice regarding each term and condition of this Agreement, that they both understand the meaning and effect of each provision contained in this Agreement, and that they have voluntarily and knowingly entered into this Agreement. Further, the Employer and Employee expressly represent and warrant that in executing this Agreement they have not relied upon any representation or statement not set forth herein made by the Employer’s or Employee’s agents, representatives, or attorneys with regard to the subject matter, basis, or effect of this Agreement or otherwise.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement as follows:

EMPLOYEE

ROADIES INC.

Name:

By: (Enter)

Title: (Enter)

Notice to Employee

Labor Code section 2810.5

Pay Rate Addendum

Non-Productive Rate – $

Rest and Recovery Rate: Not less than $ but subject to upward adjustment based on average hourly rate for the workweek.

Mileage-Based Rate: per mile driven, as calculated by .

Form I-9 Supplement,
Section 1 Preparer and/or Translator Certification

Department Of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-9
Supplement

OMB No. 1615-0047 Expires 08/31/2019

Employee Name: Last Name (Family name) First Name (Given name) Middle Initial
Instructions:This supplement may be used if extra spaces are required more than one preparer and/or translator assisting an employee in completing Section 1 of From I-9. The preparer and/or translator must enter the employee's name in the spaces provided. Each preparer or translator must complete, sign and date a seprate certification area.Employers must retain completed supplement sheets with the employee's completed Form I-9.
I attest, under penalty of perjury, that i have assisted in the completion of Section 1 of this form and that to the best of my Knowledge the information is true and correct.
Signature Of preparer Or Translater
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name) Address (Street Number and Name) City or Town
State
Zip Code
I attest, under penalty of perjury, that i have assisted in the completion of Section 1 of this form and that to the best of my Knowledge the information is true and correct.
Signature Of preparer Or Translater
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name) Address (Street Number and Name) City or Town
State
Zip Code
I attest, under penalty of perjury, that i have assisted in the completion of Section 1 of this form and that to the best of my Knowledge the information is true and correct.
Signature Of preparer Or Translater
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name) Address (Street Number and Name) City or Town
State
Zip Code
I attest, under penalty of perjury, that i have assisted in the completion of Section 1 of this form and that to the best of my Knowledge the information is true and correct.
Signature Of preparer Or Translater
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name) Address (Street Number and Name) City or Town
State
Zip Code
Form I-9 Supplement 07/17/17 N Page 1 of 1

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No. 1210-0149 (expires 5-31-2020)

PART A: General Information

When key parts of the health care law take effect in 2014, there will be a new way to buy health Insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic Information about the new Marketplace and employment based health coverage offered by your employer.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health Insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping' to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premlums in the Marketplace?

You may quality to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income

Does Employer Health Coverage Affect Ellgibility for Premilum Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by vour employer, then you may lose the employer contribution (if any) to the employer offered coverage. Also, this employer contribution -as well as your employee contribution to employer offered coverage is often excluded from income tor Federal and State income tax purposes. Your payments for coverage through the Marketolace are made on an alter-tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description of contact

The Marketplace can belp you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information including an online application for health insurance coverage and contact information for a Hoalth Insurance Marketplace in vour area


1 An employer-sponsored health plan meets the minimum value standard" If the plan's share of the total allowed benefit coats covered by the plan is no ess than 60 percent of such costs.

PART B: Information About Health Coverage Offered by Your Employer

This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application

3. Employer name
4. Employer Identification Number (EIN)
5. Employer address
6. Employer phone number
7. City (Street Number and Name) 8. State
9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above)
12. Email address

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees. Eligible employees are:

Some employees. Eligible employees are:

• With respect to dependents are:

We do offer coverage. Eligible employees are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

* * Even if your employer intends your coverage to be affordable, vou may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors to determine whether you may be eligible fer a premium discount. If. for example, vour wages vary from weok to week (perhaps you are an hourly amployee or you work on a commission basis), if you are newly employed mid year, or it you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplacs, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premlums.

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.

13.

Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?

Yes (Continue)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue)

No (STOP and return this form to employee)

14.

Does the employer offer a health plan that meets the minimum value standard*?

a. How much would the employee have to pay in premiums for this plan? $

Yes (Go to question 15)

No (STOP and return form to employee)

15.

For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Monthly

Quarterly

Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employeo.

16.

What change will the employer make for the new plan year?

Employer won't offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much would the employee have to pay in premiums for this plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Monthly

Quarterly

Yearly


An employer-sponsored health plan meets the 'minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B (c)(2)(C)(if) of the Internal Revenue Code of 1986)

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