Read Randstad Temp Driver Enrollment.PDF text version

Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339

.......................................................................................................................................... Dear Randstad HR Solutions Employee:

It is our pleasure to welcome you as a new member of Randstad HR Solutions. Randstad HR Solutions is an affiliate of Randstad Holding, nv, one of the largest staffing companies in the world and is part of a wellestablished employment solutions company with over 43 years of experience. Collectively, Randstad's business units place over 250,000 people on assignment everyday throughout the world, and 55,000 throughout North America. As part of our relationship, Randstad HR Solutions will issue weekly paychecks as well as make all required and/or authorized deductions during the period that you work for us. Attached you will find an enrollment packet that must be completed. After you have received your first paycheck, you should carefully review all information including tax status, name and address to verify that your tax deduction preferences have been followed. If you have any payroll-related questions, please call us at 1.800.382.7297. Our hours of operation are Monday through Friday 8:00 a.m. to 6:00 p.m. Eastern Standard Time. If you call at times other than those mentioned, please leave a message and we will return your call the following business day. Access your Randstad account 24/7 from any PC with Internet access. Go to Enter your username and password (you will have to create this information if you are a first time user). You will also need your employee ID number located on your paycheck, pay advice or call HRS. Choose my personal information or payroll information to begin reviewing and editing your personal data. Your safety and well-being are our primary concerns. If you are injured on a job assignment, contact HRS immediately to file an injury report at 800.382.PAYS (7297). Randstad HRS has a long-standing, well-enforced policy that prohibits illegal discrimination and/or harassment in the work place. If at any time you believe that you have been subjected to illegal discrimination, or if you know that such conduct is occurring, you have an obligation to report it to Randstad HRS. Randstad HRS investigates all claims of illegal discrimination or harassment and takes appropriate remedial action. Any employee engaging in such conduct will be disciplined up to and including discharge. Retaliation for reporting concerns about illegal discrimination or harassment will not be tolerated. Once again, we are delighted that you have become associated with Randstad HR Solutions. If you have any questions during your assignment, please do not hesitate to call us.

Sincerely, The Randstad HR Solutions Team

Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339

.......................................................................................................................................... Checklist for New Enrollment ­ FedEx

The following items must be completed and submitted back for a new Randstad HR Solutions Employee:

Temporary Agency Driver Candidate Cover Sheet Electronic I9 (Instructions included) At-Will Agreement W-4 Payment Options Form Direct Deposit Authorization Agreements and Assignment Consumer Report Disclosure Disclosure of Record FedEx Policy Acknowledgement Seasonal Temp Driver Policy

Please return enrollment documents to the following fax number using the enclosed Fax Cover Sheet or to the mailing address below: For faster processing, fax to... 1-866-530-2741 ...or mail to... Randstad HR Solutions 2015 South Park Place Atlanta, GA 30339

Randstad HR Solutions Employee must read and keep the following documents:

Welcome Letter Checklist for New Enrollment Self Service Instructions E-Verify Notice Right to Work Notice


Benefits Enrollment Within fourteen (14) days of your first paycheck date, you will be mailed a full enrollment kit by the administrator of the Randstad plan SRC, an Aetna company. You have forty-five (45) days from the date your first paycheck is issued to complete your enrollment. You will be eligible to enroll in benefits on the date your first paycheck is issued. If you do not enroll within the forty-five (45) days, you will not be able to enroll until the next open enrollment period, which is offered at the end of the calendar year, unless you have a qualifying life event family status change. If you elect to participate in the Randstad HRS benefits program, only one premium deduction will be made per paycheck. If for any reason you do not work a week or you receive two weeks pay in one check, only one premium deduction will be made. Therefore, in these circumstances, it is possible that a premium deduction will be skipped. Please review your paycheck to ensure that all required premiums have been paid. All missed premium deductions must be made up. If any premiums are missed, claims will not be paid for losses or expenses that occurred during the unpaid period(s). Premiums must be mailed within 45 days after the date on the paycheck from which the premium would have been deducted. If a missed premium is overdue by more than 45 days, it cannot be made up.


Last revision date ­ 09/26/06

Temporary Agency Driver Candidate Cover Sheet

IF candidate is sourced by...

FedEx Ground Randstad


This cover sheet must be completed by terminal management and placed on top of the temporary driver's finalized packet All other paperwork should be complete; send this sheet to Randstad communicate terminals and FedEx ID

Enter data here


FedEx ID: Temporary Driver Name: (Print only) Domiciled facility Additional Eligible Facilities (if applicable) Last 4 digits-SSN Today's date Temp's actual start date Facility contact

Manager name: Manager's employee ID: Phone number: Facility city, state:


First Name: Last Name: Temp's home state:


First Name: Last Name: Temp's home state:

0____ 0____ 0____ 0____ ____ _ _/ _ _/_ _ _ _/ _ _/_ _

(Must be after today's date)

0____ 0____ 0____ 0____ ____ _ _/ _ _/_ _ _ _/ _ _/_ _

Ground FHD



If the file is incomplete or paperwork is incorrect, the start date for the temporary driver can be delayed up to 7 days. Make copies of every packet before sending and retain at the terminal. Until you see this temporary driver on the Temp Driver Status listing in CDAS, you cannot put them on the road or in SAFE. If you do not see this within 3 business days of sending packet to Randstad, check CDAS for approvals (if unsure of CDAS inquiry, see your AQM) and then contact the closest Randstad branch for resolution.

Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339


Beginning Tuesday, September 1, 2009, the Randstad process for completing the I-9 has changed. Electronic I-9 TALENT INSTRUCTIONS STEP 1: As the Talent, you will use your web browser to navigate to: STEP 2: Once on the webpage, you will enter EMPLOYER CODE: 13698 in the "Start a New I-9" section. STEP 3: You will enter your personal information and select your work status. Once complete, you will review the information entered and then using an electronic signature pin**you will submit. **Please note you must use your first, middle and last initials for your electronic pin. If you do not have a middle initial, you will only use your first and last initials. You will need to provide to your Hiring Manager either 1 item from List A, or 1 item from List B and 1 item from List C. on your first day of work. STEP 4: Once complete, log out. STEP 5: Let hiring manager know that you have completed your I-9 section so they can complete Section 2 and your I-9 can be processed. If you are not able to complete your I-9 electronically, please contact the Randstad HR Solutions Client Care Center at 1.800.382.7297.

Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339

.......................................................................................................................................... At-Will Agreement

The undersigned employee agrees and understands that he/she is being offered employment by Randstad HRS on an at-will basis for a specific project or undertaking and that his/or employment is limited to the duration of such project or undertaking. The employee also understands and acknowledges that his/her employment is only with Randstad HRS and that he/she is not an employee of any of Randstad HR Solution's clients. The employee further understands that... Randstad HR Solutions may terminate his/her employment at anytime without notice and with or without cause. The employee is required to contact the Company (1.800.382.7297) immediately after the completion of any assignment for the purpose of requesting a new assignment, and remain in contact with the Company indicating availability for assignments, and failure to do so will constitute a voluntary resignation that may affect my eligibility for unemployment benefits. The employee agrees and authorized Randstad HR Solutions to deduct and withhold from the employee's paycheck all Federal, State, and any other Local taxes as applicable. The employee also authorizes Randstad HRS to deduct and withhold the appropriate FICA taxes from the employee's paycheck. The employee further agrees that upon termination of the employment relationship, there will be no further obligation or responsibility on the part of Randstad HRS, or its clients, to the employee. By the employee's signature below, the employee acknowledges that he/she understands the above, and that he/she voluntarily agrees to its terms.

Print name______________________________________________ Date______________________________________________ Signature_______________________________________________ Social Security Number________________________________ Phone__________________________________________________ Email______________________________________________ Company_______________________________________________ Approver/Manager(Please PRINT)_______________________

Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339 .......................................................................................................................................... Payment Options Randstad HR Solutions offers two convenient payment options. Please take the time to review the below information and choose the one that works best for you. You may change your preferred method of payment once you have been issued a Randstad employee ID by visiting the Randstad Self Service website at Your designated payday will be every Friday, provided you submit your approved timecard before noon the prior Monday.

1. Direct Deposit. I select direct deposit for disbursement of my pay. I hereby authorize my employer and Financial Institution listed to deposit my net pay automatically to the account listed each payday and to initiate adjustments, if necessary, for any entries made in error to my account. This authority is to remain in effect until my employer or Financial Institution has received notification from me of its termination in such time and such manner as to afford my employer and Financial Institution a reasonable opportunity to act on it. 2. The ADP TotalPay card. I select the ADP TotalPay Payroll Distribution Service, which allows me to access my wages from anywhere in the U.S. at anytime by pay card or by check on payday morning. I understand that there is no monthly charge for the card and I will not incur a fee if I cash an ADP TotalPay Check for the full amount of my wages each pay period. However, I also understand that there are fees for certain transactions. I have reviewed and agree to the ADP TotalPay Service Fee Schedule and the ADP TotalPay Service Terms and Conditions located at 1

Name: __________________________________________________ Date_________________________ Signature: ____________________________________________________________________________ Address: ______________________________________________________________________________ Phone: _______________________________________________________________________________ Email: ________________________________________________________________________________


When you select ADP TotalPay Payroll Distribution Service, you have the option of using the ADP TotalPay ChecksTM or the ADP TotalPay Card. You can use the ADP TotalPay Card to get your pay through ATM withdrawals, at a bank teller, and you can make purchases at stores, and get cash back with those purchases. You can access your full wages by completing and authorizing a convenient check that is cashable free of charge at ADP TotalPay encashment centers near you or you can choose to use the ADP TotalPay Check to access only the amount of your wages that you actually need at a given time and use additional free ADP TotalPay Checks to access your wages as needed. You can also use the ADP TotalPay Checks to pay bills or family and friends.

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Direct Deposit Authorization

Please complete both sides of this form and return to your Branch office. Type of authorization Name Branch name new enrollment change Social security number Branch number

Financial institution information

Name Street address Type of account checking savings City/state/zip

Account number (one account only) Routing number Phone

Authorization statement

I authorize Randstad and financial institution listed above to deposit my net pay automatically to the account listed above each payday and to initiate adjustments, if necessary, for any entries made in error to my account. This authorization will remain in effect until I cancel it in writing. Signature Date

Other information

It may take up to two business days for Direct Deposit to begin after your authorization has been completed and returned. Please be sure your employee time record is submitted by 12:00 noon every Monday.

Attach copy of a voided check below.


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Direct Deposit check list

Please read the following information carefully. Be sure that Direct Deposit is the method by which you want to receive your pay. Changing the method by which you receive your pay could result in a delay in receiving your pay. · · · · I understand that I will have only one Financial Institution account for my Direct Deposit. I understand that if I have a question or concern with my Direct Deposit, I should call the ACH Department at my local Financial Institution. I understand that if I should close my account or if my account number changes I will notify my Randstad Branch. I understand that if I do not make my Branch aware that my account has been closed or changed, my money will not be available to me until the funds are transferred back from the Financial Institution to Randstad. A manual check cannot be written. Randstad North America reserves the right to initiate credit entries for regular payroll payments in accounts as indicated, and to initiate, if necessary, debit entries and adjustments needed to correct any credit/debit errors to those accounts, and also authorize the receiving Financial Institution to credit and/or debit the same to such accounts. Do not use the routing numbers found on the bottom of your deposit slips. Payment advice will be sent to the address provided by talent. I further understand that the Randstad North America reserves the right to reject my election of this method of payment.


· · · Talent name (please print) Talent signature Branch representative


Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339

.......................................................................................................................................... Agreements and Assignment

Agreement and Waiver

In consideration of my assignment to Client by Randstad HR Solutions, I agree that I am solely an employee of Randstad HR Solutions for benefits plan purposes and that I am eligible only for such benefits as Randstad HR Solutions may offer to its employees. I further understand and agree that I am not eligible for or entitled to participate in any benefit plan offered by Client, its parents, affiliates, subsidiaries, or successors to any of its direct employees, regardless of the length of my assignment to Client by Randstad HR Solutions and regardless of whether I am held to be a common-law employee of Client for any purpose, and therefore, with full knowledge and understanding, I hereby expressly waive any claim or right that I may have, now or in the future, to such benefits and agree not to make any claim for such benefits.

Employee confidentiality Agreement

As a condition of my assignment by Randstad HR Solutions to Client, I hereby acknowledge and agree as follows: I will not use, disclose, or in any way reveal or disseminate to unauthorized parties any information I gain through contact with materials or documents that are made available through my assignment at client or that I learn about during such assignment. I will not disclose or in any way reveal or disseminate any information pertaining to client or its operating methods and procedures that come to my attention as a result of this assignment. Under no circumstances shall I remove copies or documents from the premises of client. I understand that I shall be responsible for any direct or consequential damages resulting from any violation of this agreement. The obligation of this Agreement shall survive my employment by Randstad HR Solutions.

In connection with my assignment to provide services to Client, I agree that any and all discoveries and /or inventions (whichshall include improvements and modifications) relating to work I perform while providing services to Client, or relating to matters disclosed to my by Client, in connection with work to be performed, or suggested by such matters, whether or not patentable, which discoveries and/or inventions are made or conceived by me, solely or jointly with others, during the term of my assignmen t (regardless of whether conceived or developed during work hours) or during a period of one (1) year thereafter, shall be the property of Client as "work made for hire" to the extent provided by sections 101 and 201(b) of the Copyright Act, 17 U.S.C. 10 1 et.seq., and such discoveries and/or inventions shall be promptly disclosed to Client. Client shall have the right to file and prosecute, at its own expense, all patent applications, whether U.S. or foreign on said discoveries and/or inventions. I shall during , any assignment to Client or at any time thereafter, provide to Client all documents, information, and assistance requested for the filing or prosecution of any such patent, application, for the preparation, prosecution, or defense of any legal action or appl ication pertaining to such discoveries and/or inventions and for the assignment or conveyance to Client of all right, title, and interest in and to such discoveries and/or inventions, patent applications, and letters patent issuing thereon. Randstad HR Solutions employee Signature____________________________________________________ _Date________________________________ Printed name_________________________________________________ Witness Signature____________________________________________________ Printed name_________________________________________________ Date_____________________________

Assignment of Copyright and Patents

Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339

.......................................................................................................................................... Consumer Report Disclosure and Authorization for Employees

I hereby acknowledge and understand that in connection with my employment relationship and/or application for a position with Randstad North America, LP, its subsidiaries, affiliates, business units and/or successors (collectively "the Company"), the Company may procure or cause to be procured consumer reports which contain information about me. These consumer reports may contain information such as, my credit history, criminal record, motor vehicle record, driving record and/or motor vehicle accident record, which may be obtained from government or private entities which maintain such records. The Company may obtain these consumer reports directly, or it may obtain them through a consumer reporting agency. I further acknowledge and understand that the Company may share and transfer information reported on or learned from these consumer reports to its client, for whom I wish to be considered for temporary and/or permanent employment, assignment or placement. I further acknowledge and understand that I have a right to request certain information from any consumer reporting agency which provides a consumer report to the Company, and that I have the right to dispute inaccurate information with the consumer reporting agency. Further, if the Company takes an adverse action against me based on whole or in part upon a consumer report provided by a consumer reporting agency, I will be informed of that fact, given a report provided by a consumer reporting agency. I will be informed of that fact, given a summary of my rights under the fair credit reporting act, provided with a copy of the consumer report, and given the name, address, and telephone number of the consumer reporting agency that provided the consumer report. I hereby authorize the Company to procure consumer reports including but not limited to information about my credit history, criminal, record, motor vehicle record, driving record, and motor vehicle accident record, from any consumer reporting agency. I hereby further authorize the Company to share and transfer information reported on or learned from these consumer reports to its clients, for whom I wish to be considered for temporary and/or permanent employment, assignment or placement. This authorization shall remain on file with the Company throughout the duration of my employment relationship with the Company (if any), and shall serve as ongoing authorization for the Company to procure consumer reports at any time during my employment with the Company (if any) and to share and transfer information reported on and learned from these consumer reports to its clients, for whom I wish to be considered for temporary and/or non-temporary employment, assignment or placement. Employee name (please print) ____________________________________________________________________________ Street address_________________________________________________________________________________________ City/state/zip__________________________________________________________________________________________ Print all former names used_______________________________________________________________________________ Date of birth (will be used for identification purposes only) ______________________________________________________ Gender Male Female

Social security number (will be used for identification purposes only) ______________________________________________ Driver's license state of issue (will be used for identification purposes only) _________________________________________ Driver's license number________________________________________ Driver's license expiration date_________________ Motor vehicle policy number_______________________________________________________________________________ Insurance carrier______________________________________________Policy expiration date_________________________ Employee signature____________________________________________Date______________________________________

Disclosure of Record

Applicant name Answering "yes" to any of the questions below is not an automatic bar to employment.

For California applicants only Have you ever been convicted of a felony which has not been expunged or sealed by a Court? yes no

If "yes," please explain. California applicants may omit any convictions for the possession of marijuana (except for convictions for the possessions of marijuana on school grounds or possession of concentrated cannabis), possession of marijuana pipes or paraphernalia, operation of a business that displays or sells marijuana paraphernalia in areas accessible to minors, or being under the influence of marijuana, that are more than two (2) years old, and any information concerning a referral to, and participation in, any pre-trial or post-trial diversion program.

For Connecticut applicants only Have you ever been convicted of a felony which has not been expunged or sealed by a Court? yes no

If "yes," please explain. Connecticut applicants are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased."

For New Hampshire applicants only Have you been convicted of a felony that has not been annulled by a Court? If "yes," please explain. yes no

For New York applicants only Have you ever been convicted of a felony which has not been expunged or sealed by a Court? yes no

If "yes," please explain. New York applicants should not disclose any information pertaining to any youthful offender conviction.

For Washington, D.C. applicants only Have you been convicted of a felony within the last ten (10) years which has not been expunged or sealed by a Court? If "yes," please explain. yes no


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For Washington applicants only Have you been convicted of a felony within the last seven (7) years which has not been expunged or sealed by a Court? If "yes," please explain. yes no

For all other applicants (except Hawaii and Massachusetts applicants ­ all of whom should skip this question) Have you ever been convicted of a felony which has not been expunged or sealed by a Court? If "yes," please explain. yes no


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SF-015 5/08

SAFE Driver Program Policy Acknowledgement

The undersigned hereby acknowledges that he/she understands that Contractors' employees and temporary drivers who begin the FedEx Ground ("FXG") or FedEx Home Delivery ("FHD") SAFE Driver Program after November 1, 2006 are not eligible to become independent contractors for FXG or FHD and/or are not eligible to drive for FXG or FHD as a contractor by acquiring an ownership interest in the business of an existing contractor until the later of: (1) one year following their completion of the SAFE Driver Program, or (2) one year from the last date of service for FXG or FHD as an employee of a temporary employment agency. The one-year waiting period will not apply to attendees who completed the SAFE Driver Program prior to November 1, 2006 or to attendees who were enrolled in the SAFE Driver Program as of October 31, 2006. The waiting period applies only to those individuals who attend the SAFE Driver Program conducted by FXG or FHD. The waiting period also does not apply to employment as employees ("supplementals" or helpers) of independent contractors under contract to FXG or FHD.

________________________________ Signature ________________________________ Typed or Printed Name ________________________________ Date

Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339


Welcome Seasonal Temp Driver!

Before we begin working with you, we would like to make sure that you understand the temporary nature of this position. As an employee of Randstad Work Solutions, you have been temporarily assigned to FedEx Ground. Accordingly, this assignment may end at any time, without notice and with or without cause. Please sign below to confirm that you understand the temporary nature of this position.



__________________________________ Witness

Randstad HR Solutions 2015 S Park Place Atlanta, GA 30339 T - 800.382.PAYS (7297) F ­ 1-866-530-2741

.......................................................................................................................................... Fax Message

To Randstad HR Solutions Attention From Fed-Ex Date


Fax _ _ 1-866-530-2741_______


Number of pages with cover sheet _________________________________________ Telephone _________________________________________

Please use this fax cover sheet to send Enrollment Packet


Quick Start Guide Self Service Instructions

Once you become a Randstad employee, you have access to the Self Service website - Through Self Service you have the ability to: View & Print pay statements online Reprint prior year W-2's Update federal W-4 information Change direct deposit information Change home or mailing address Change contact information

Registration: Make sure you are using the Internet Explorer browser, Netscape is not supported. Go to the Self Service website: Select the "New User" box on the right side of the webpage You will be directed to the Randstad Self Service User Activation Screen You will be required to provide your Randstad Employee I.D. number ­ please call the Randstad Customer Care Center at 1-800-382-7297 to obtain this number. Fill in your last name and social security number You will then need to establish a self service user I.D. and password ­ determined by you (please write this information down and keep it in a safe place). Continue with registration by selecting and answering safety question and entering your email address. Please note ­ this email address will be used to email forgotten password, notification of pay, and notification of any changes. After Randstad Self Service User Activation Screen has been completed select the "proceed to next step" button to continue process. You will see an "ePay Consent" form, recommending that you consent to receive electronic pay statements as opposed to paper statements going forward. Once you have made your choice, select the "Submit" button. On the following page select the "OK" button to return to the main login page. Using Self Service: When you login, you will arrive at the Randstad Self Service home page. Here you will find links to "Personal Information" and "Payroll Information". Click any of these links to access your information and make any necessary updates or changes. From this home page, you can also update your user profile for this website.

This Employer Participates in E-Verify

This employer will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee's Form I-9 to confirm work authorization. IMPORTANT: If the Government cannot confirm that you are authorized to work, this employer is required to provide you written instructions and an opportunity to contact SSA and/or DHS before taking adverse action against you, including terminating your employment. Employers may not use E-Verify to pre-screen job applicants or to re-verify current employees and may not limit or influence the choice of documents presented for use on the Form I-9.

In order to determine whether Form I-9 documentation is valid, this employer uses E-Verify's photo screening tool to match the photograph appearing on some permanent resident and employment authorization cards with the official U.S. Citizenship and Immigration Services' (USCIS) photograph. If you believe that your employer has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of Special Counsel at 1-800-255-7688 (TDD: 1-800-237-2515).

N O T I C E:

Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States.

For more information on E-Verify, please contact DHS at:


IF YOU HAVE THE RIGHT TO WORK, Don't let anyone take it away.

If you have a legal right to work in the United States, there are laws to protect you against discrimination in the workplace.

You should know that ­ No employer can deny you a job or fire you because of your national origin or citizenship status. In most cases employers cannot require you to be a U.S. citizen or permanent resident or refuse any legally acceptable documents.

If any of these things have happened to you, you may have a valid charge of discrimination that can be filed with the OSC. Contact the OSC for assistance in your own language.

Call 1-800-255-7688. TDD for the hearing impaired is 1-800-237-2515. In the Washington, D.C., area, please call 202-616-5594, TDD 202-616-5525 Or write to: The Office of Special Counsel Civil Rights Division U.S. Department of Justice P.O. Box 27728, Washington, DC 20038-7728

U.S. Department of Justice Civil Rights Division Office of Special Counsel for Immigration-Related Unfair Employment Practices

Aetna Affordable Health Choices Medical Coverage

Both medical options include pharmacy and vision care discounts, Informed Health® Line*, and Employee Assistance Program at or 1-888-238-6232.Medical coverage is subject to exclusions and limitations. Refer to member materials for full details.

N e t Pre Mier 5 in-Network Out-of-Network

Aetna Affordable Health Choices Other Supplemental Coverages

In addition to the Aetna Affordable Health Choices limited medical insurance benefits, you also have other coverages available to you and your dependents. Coverages are subject to exclusions and limitations. Refer to member materials for full details.

COV erAge

MeDiCAL You may enroll in one medical option only. Net Premier 5 Yourself Only Yourself Plus One Yourself and Family Net Premier 10 Yourself Only Yourself Plus One Yourself and Family SuPPLeMeNtAL You may choose any combination of coverages. Vision Yourself Only Yourself Plus One Yourself and Family Dental Yourself Only Yourself Plus One Yourself and Family Short-Term Disability (Yourself Only) $100 Maximum Weekly Benefit $200 Maximum Weekly Benefit $300 Maximum Weekly Benefit Term Life Insurance $10,000 Yourself Only $10,000 Yourself & $2,500 Family $20,000 Yourself Only $20,000 Yourself & $2,500 Family $30,000 Yourself Only $30,000 Yourself & $2,500 Family Hospital Indemnity Plan Yourself Only Yourself Plus One Yourself and Family

weeKLy COSt

Aetna Affordable Health Choices exclusions and Limitations

This plan does not cover all health care expenses and has exclusions and limitations. Members should refer to their booklet certificate to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan may contain exceptions to this list based on state mandates or the plan design purchased.

Vision Care

The vision care coverage provides reimbursements of up to $100 every 12 months for an exam, frames, lenses, or contact lenses. Benefits apply to each covered person. Additional Aetna VisionSM discounts can be used by the whole family. Discount program provides access to discounted prices and is not an insured benefit; and may not be available to Illinois residents.

$27.41 $69.65 $98.99 $32.60 $82.83 $117.68

Maximum benefit: per covered person per plan year $5,000 in- or out-of-network Limit on Other Hospital Services $1,000 in- or out-of-network Limit on outpatient charges $1,000 in- or out-of-network Annual deductible Coinsurance you pay $100 (individual) $200 (family) 20% $200 (individual) $400 (family) 40%

Medical Pre-existing Condition Limitation

This plan imposes a pre-existing condition exclusion. This means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within the 180 days prior to your enrollment in this plan. Generally, this 180-day period ends on the day before the medical plan waiting period begins (for example, on your date of hire). The pre-existing condition exclusion does not apply to pregnancy or to children under 19 years of age including a newborn child or a child who is enrolled in the plan within 30 days after birth, adoption, or placement for adoption. This exclusion may last up to 365 days from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days of your prior "creditable coverage." Please contact us at 1-888-772-9682 if you need help demonstrating creditable coverage.


The dental insurance covers most common dental services and includes a PPO network of dentists for you to choose from. If you choose one of these preferred dentists, your dental expenses will usually be lower than a non-participating dentist. (PPO network not available to members in AL, AR, ID, HI, LA, MS, NM, or PR.) After you meet your deductible, the plan pays 50 to 80 percent of recognized charges, according to a schedule of covered services. Basic services require a 3-month waiting period and major services require a 12-month waiting period before they are covered. Preventive services have no waiting period.

Supplemental inpatient benefit annual maximum** $45,000 in- or out-of-network Doctor's office visits Retail/Walk-in Clinic Preventive visits Annual maximum Prescription drugs Monthly maximum N e t PreMi er 10 $15 copay $10 copay $15 per visit deductible; $10 deductible 20% thereafter

$1.00 $1.70 $2.40 $4.45 $8.90 $14.69 $2.80 $5.60 $8.40 $0.77 $1.11 $1.54 $1.88 $2.31 $2.65

Short-term Disability

This coverage is designed to provide 50% base pay in the event that you have an illness or injury that prevents you from working. Choose from three benefit levels: $100, $200, or $300 per week maximum. Covers 50% of base pay up to benefit level selected. (Coverage not available in CA, HI, NJ, NY, RI, or PR.)

$15 copay 20% $100 in- or out-of-network $10 generic copay 20% $20 brand copay $35 in- or out-of-network in-Network Out-of-Network

Medical and Hospital indemnity Plan exclusions


term Life and Accidental Death insurance

Term life and accidental death insurance can bring great peace of mind, without great expense. You may choose $10,000, $20,000, or $30,000 in term life insurance coverage that includes a matching $10,000, $20,000 or $30,000 accidental death benefit for yourself only. You may also purchase term life insurance coverage for your spouse and eligible dependent children.

n n n n

Maximum benefit: per covered person per plan year $10,000 in- or out-of-network Limit on Other Hospital Services $1,000 in- or out-of-network Limit on outpatient charges $1,250 in- or out-of-network Annual deductible Coinsurance you pay $100 (individual) $200 (family) 20% $200 (individual) $400 (family) 40%

Hospital indemnity Plan

If you or a covered family member is admitted to the hospital as an inpatient, you receive:

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$3.45 $6.90 $10.35

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$1,000 for one stay in the hospital during the coverage year, plus $100 each day, for up to 100 days you are in the hospital during the coverage year Your benefit premiums are paid through convenient payroll deductions. Deductions will be taken before taxes in MA, CT, KS, MN, MO, RI and WA. (STD, and Term Life deductions will be taken after taxes.) In these states you will not be able to drop your coverage unless you have a family status change. If you miss a deduction you can continue your coverage by submitting a payment directly to SRC along with a missed premium form (available online or by calling SRC at 1-800-722-1074). When you and your family members use a provider in the Aetna PPO network, your health care costs could be significantly lower than if you use a non-network provider.

Supplemental inpatient benefit annual maximum** $45,000 in- or out-of-network Doctor's office visits Retail/Walk-in Clinic Preventive visits Annual maximum Prescription drugs Monthly maximum $15 copay $10 copay $15 per visit deductible; $10 deductible 20% thereafter

Key terms

Outpatient charges are charges billed for services and supplies provided at doctors' offices, free-standing clinics and outpatient facilities. They also include charges at a hospital when you are not admitted as an inpatient, including emergency room charges. Inpatient charges are all charges incurred when you are admitted as an inpatient at a hospital or other inpatient facility, including hospital room and board charges (daily room rate), Inpatient Professional Services, and Other Hospital Services. Other Hospital Services are charges for certain services and supplies billed by a hospital when you are admitted as an inpatient, other than those charges for room and board. These charges may be significant and may include, but are not limited to: pharmaceutical, medical and surgical supplies and devices; lab tests and x-rays; and operating and recovery room expenses. They do not include Inpatient Professional Services. Inpatient Professional Services are charges billed by surgeons, physicians, radiologists, pathologists and anesthesiologists for services provided during an inpatient stay.

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$15 copay 20% $100 in- or out-of-network $10 generic copay 20% $20 brand copay $75 in- or out-of-network

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All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents. Any eye surgery mainly to correct refractive errors. Cosmetic surgery, including breast reduction. Custodial care. Dental care and X-rays, unless medically necessary to repair an injury to the mouth, jaw, or teeth resulting from an accident. Donor egg retrieval. Experimental and investigational procedures. Hearing aids. Immunizations for travel or work. Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies. Nonmedically necessary services or supplies. Orthotics. Over-the-counter medications and supplies. Reversal of sterilization. Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling. Special-duty nursing. Treatment of alcoholism, drug abuse and mental/behavioral disorders (except where state mandated).

* While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide information on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health care needs. **Maximum benefit per coverage year must be exhausted first. Other Hospital Services are not covered. Room and board charges and Inpatient Professional Services are covered.

Aetna Affordable Health Choices exclusions and Limitations

(continued from reverse) Vision Care exclusions


Randstad recognizes you as an important part of our company's success.

If you keep up with national news, you know there is a serious problem locating affordable health care in the United States. We value our employees and their families; this is why we are offering this limited-benefits insurance program through Aetna. As an employee, you and your family members are eligible to participate in the Aetna Affordable Health Choices plan. This limited-benefits insurance plan offers two medical options, vision care, dental, short-term disability, hospital indemnity and term life with accidental death coverage. You can elect any of these benefits separately, based on your needs. Short term disability insurance coverage is available for you only. PLEASE READ CAREFULLY BEFORE DECIDING WHETHER THIS PLAN IS RIGHT FOR YOU:


How do i enroll?

Read your Aetna Affordable Health Choices enrollment kit. It provides more details on weekly premium costs, covered services, maximum benefits, and instructions to enroll yourself and your family. As a new hire, you have 45 days from the issue date of your first paycheck to enroll. You can enroll immediately, but your coverage will not begin until after your first deduction. Once enrolled, deductions will begin one to two pay periods after your first paycheck. Weekly coverage becomes effective on the Monday following the first payroll deduction and each subsequent payroll deduction. You will have another opportunity to enroll during the annual open enrollment period in December each year for coverage effective the following January. To review your enrollment materials and enroll online:


Welcome to Randstad®

Aetna Affordable Health Choices®

Limited benefits insurance plan*

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Orthoptic vision training, subnormal vision aids, and any associated supplemental testing. Medical and/or surgical treatment of the eyes or supporting structure. Any eye or vision examination, or any corrective eyewear, required by an employer as a condition of employment.

Dental exclusions

The following charges are not covered under the dental plan coverage, and they will not be recognized toward satisfaction of any deductible amount.

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Cosmetic procedures, unless needed as a result of injury. Any procedure, service, or supplies that are included as covered medical expenses under another group medical expense benefit plan. Prescribed drugs, pre-medication, analgesia or general anesthesia. Services provided for any type of temporomandibular (TMJ) or related structures, or myofascial pain. Charges in excess of the Recognized Charge, based on the 80th percentile of the Ingenix Medical Data Research Tables.

Log on with the User Name/ Group# 382370 and the Password/Access Code 2374. To enroll by telephone, please call 1-800-772-1074. Your Access Code is 2374. For Randstad HR Solutions log on to, enter User Name/ Group# 383230 and Password/Access Code 2316. To enroll by telephone, please call 1-800-772-1074. Your Access Code is 2316.


Short-term Disability exclusions


This plan will not pay more than the overall maximum benefit in a coverage year. This plan also limits what it will pay for particular kinds of services in addition to the overall annual maximum benefit. Once any of these limits have been reached, the plan will not pay any more towards the cost of the service in question, and your health care providers can bill you for what the plan does not pay. Many illnesses cost much more to treat than this plan will cover. This document explains these limits, the overall annual maximum benefit, and other cost sharing features of your plan, such as copayments and deductibles. See the full Benefits Summary in your enrollment kit and the plan documents for more information.


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Attempted suicide, while sane or insane, or intentional self-inflicted injury or sickness, unless as the result of a medical condition. Commission of, or attempt to commit an act which is a felony in the jurisdiction in which the act occurred. Substance abuse. Occupational injury or sickness.



For more information or to order an enrollment kit, please call SRC at 1-800-772-1074.

welcome to the randstad team!

Policy forms issued in OK include: GR-9/GR-9N and/or GR-29/GR-29N.This material is for information only. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Health, dental, life, and disability insurance plans contain exclusions and limitations. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Not all health, dental and disability services are covered. See plan documents for a complete description of benefits, exclusions, limitations, and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is believed to be accurate as of the production date; however, it is subject to change.

Health insurance for employees

term Life exclusions



Suicide or attempted suicide (while sane or insane). Use of alcohol, intoxicants, or drugs, except as prescribed by a physician. Suicide or attempted suicide (while sane or insane). An intentionally self-inflicted injury. A disease, ptomaine or bacterial infection, except for that which results directly from an injury. Medical or surgical treatment, except for that which results directly from an injury. Voluntary inhalation of poisonous gases. Commission of or attempt to commit a criminal act.

Accidental Death Benefit exclusions


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This health insurance issuer believes this plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). Being a grandfathered health plan means that your plan does not include certain consumer protections of the Affordable Care Act. 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 1-888-772-9682. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or or


Health insurance Plans are underwritten by Aetna Life insurance Company. Plans are administered by Strategic resource Company (SrC). Aetna Affordable Health Choices® is a registered service mark of Aetna Inc. *Except in NY, this plan is filed as a major medical plan that contains an annual benefit maximum and a number of additional coverage limitations and exclusions.

12.02.336.1-Randstad (11/10)

©2010 Aetna Inc. 12.02.336.1-Randstad (11/10)


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