| Invoice Number: | 148348 |
| Reconciliation Period: | 01/01/2007 - 01/31/2007 |
| Master Number: | 03000-00 |
| Group Number: | 93705-000-00000-00000 |
| Description: | |
| Phone Number: | (999) 999-0000 |
| SELF INSURED |
| BENEFITS ADMINISTRATOR |
| 321 UNIVERSITY AVENUE |
| ANYWHERE, USA 55555-0000 |
| ACTIVE SUBSCRIBERS |
|---|
| Member Number | Member Last Name | Member First Name | Effective Date | Coverage |
|---|
| 00989776543 | ADAMS | SARAH | 01/01/2005 | S+Family |
| 00213456789 | ALBERTSON | BRENDA | 08/01/2006 | S+Family |
| 00652331254 | ALLEN | SALLY | 01/01/2005 | S+Family |
| 00456789012 | ALOMAR | MARIA | 08/01/2006 | S+Family |
| 00652698745 | AVERY | HEATHER | 01/01/2005 | Single |
| 00220563429 | BERG | DORIS | 01/01/2007 | S+Family |
| 00642153297 | BOONE | ROBERT | 01/01/2005 | S+Family |
| 00123456789 | BROWN | SHEILA | 01/01/2005 | Single |
| 00654418897 | CARLSON | DONALD | 07/01/2006 | Single |
| 00666778888 | CHASE | THOMAS | 11/01/2006 | Single |
| 00909090909 | COOPER | DUSTON | 04/01/2006 | S+Family |
| 00232123152 | DETMER | CLARENCE | 01/01/2005 | S+Family |
| 00884562917 | DONALDSON | RYAN | 01/01/2005 | S+Family |
| 00332362514 | GARRISON | ALFRED | 01/01/2005 | Single |
| 00222114444 | GAUSS | PERRY | 04/01/2006 | S+Family |
| 00654241595 | GILBERT | BETH | 01/01/2005 | S+Family |
| 00113425697 | GILMORE | REBECCA | 01/01/2007 | S+Family |
| 00652392687 | GLAZA | PETER | 10/01/2006 | S+Family |
| 00123546789 | GONZALEZ | JESUS | 01/01/2005 | S+Family |
| 00114741259 | GREEN | LINDA | 07/01/2005 | S+Family |
| 00505050505 | GREENE | JANET | 01/01/2005 | Single |
| 00325325652 | GUNN | HILARY | 01/01/2005 | S+Family |
| 00606060606 | HAGEN | DEBRA | 08/01/2005 | Single |
| 00526134082 | HAMM | ANGELA | 01/01/2005 | S+Family |
| 00999112222 | HENESSEY | BRIAN | 01/01/2005 | S+Family |
| 00707070707 | HERMANN | STEVEN | 08/01/2005 | S+Family |
| 00808080808 | HEWITT | RAYMOND | 01/01/2005 | S+Family |
| 00121134121 | HOUSTON | PATRICIA | 08/01/2005 | Single |
| 00666666666 | HUGHES | LAURA | 01/01/2006 | Single |
| 00332133213 | HUNTINGTON | WENDY | 08/01/2006 | Single |
| 00132459876 | IVANSKI | ELAINE | 01/01/2005 | S+Family |
| 00222334444 | JOHNSON | KENNETH | 01/01/2005 | Single |
| 00303030303 | KELLER | LOUISE | 01/01/2005 | S+Family |
| 00213056241 | KEYSER | RENEE | 01/01/2005 | S+Family |
| 00774512398 | KNAPP | WILLIAM | 01/01/2005 | S+Family |
| 00321456987 | KOWALSKI | BRAD | 02/01/2005 | S+Family |
| 00689565874 | KRUEGER | MATTHEW | 01/01/2005 | S+Family |
| 00111223333 | LANG | JASON | 01/01/2005 | S+Family |
| 00654777149 | LARSON | BRANDON | 01/01/2005 | S+Family |
| 00353562895 | LEE | CRYSTAL | 01/01/2005 | S+Family |
| 00333333333 | LEWIS | SHAYNA | 01/01/2005 | Single |
| 00101010101 | MARKS | LYLE | 01/01/2007 | S+Family |
| 00265412564 | MARTINEZ | ANGELA | 01/01/2005 | Single |
| 00623541578 | MCDONALD | PAUL | 01/01/2005 | Single |
| 00444556666 | MCKINELY | HELEN | 01/01/2005 | Single |
| 00542418975 | MEAD | PHILLIP | 09/01/2005 | S+Family |
| 00653251298 | MILLER | STUART | 01/01/2005 | S+Family |
| 00541147485 | MORRIS | AMY | 05/01/2006 | S+Family |
| 00452154129 | OH | KIM | 01/01/2005 | S+Family |
| 00454123412 | OLSON | GLADYS | 01/01/2005 | Single |
| 00528419367 | PENNINGTON | CHARLES | 01/01/2007 | Single |
| 00123456789 | POOLE | RICHARD | 01/01/2005 | S+Family |
| 00555555555 | PORTER | ELIZABETH | 06/01/2006 | S+Family |
| 00888888888 | POWELL | TERRENCE | 01/01/2005 | S+Family |
| 00261749538 | PRATT | EARL | 01/01/2005 | S+Family |
| 00652398741 | RAMSEY | KERRI | 01/01/2005 | S+Family |
| 00111111111 | REICH | JOHN | 01/01/2005 | S+Family |
| 00555667777 | ROBERTS | BRUCE | 09/01/2006 | S+Family |
| 00888991111 | ROGERS | PATRICK | 11/01/2006 | S+Family |
| 00999999999 | RUIZ | JOHN | 01/01/2005 | S+Family |
| 00262654162 | RUNYON | PAULINE | 05/01/2005 | S+Family |
| 00202020202 | SCHNEIDER | HARVEY | 01/01/2005 | Single |
| 00444444444 | SMITH | DAVID | 01/01/2005 | Single |
| 00333456789 | STONE | KERWIN | 01/01/2007 | S+Family |
| 00992992541 | THOMPSON | EDWARD | 01/01/2005 | S+Family |
| 00333445555 | VANG | DAO | 01/01/2005 | S+Family |
| 00321549876 | VAUGN | DIANE | 01/01/2005 | S+Family |
| 00626285945 | VILLANUEVA | GUADALUPE | 01/01/2005 | Single |
| 00404040404 | VIZQUEL | ALEX | 04/01/2005 | Single |
| 00565456485 | VIZQUEL | OMAR | 01/01/2005 | S+Family |
| 00888991111 | VOLK | CHRISTINE | 01/01/2005 | S+Family |
| 00999112222 | WALKER | KYLE | 07/01/2006 | Single |
| 00333552222 | WARFIELD | LINDA | 01/01/2005 | S+Family |
| 00222114444 | WHITE | ELMER | 01/01/2005 | S+Family |
| 00454123421 | WHITNEY | NORBERT | 01/01/2005 | S+Family |
| 00652987451 | WINGER | FRED | 01/01/2005 | Single |
| 00231548970 | WINKELMAN | CINDY | 01/01/2006 | S+Family |
| 00456789012 | WINTERS | CONNIE | 01/01/2005 | S+Family |
| 00321324121 | WU | SHIGERA | 01/01/2005 | Single |
| 00657444849 | YANG | HOUA | 10/01/2005 | Single |
| 00445464129 | YOUNG | DONITA | 01/01/2005 | S+Family |
| 00123456798 | ZELLMER | JANET | 01/01/2005 | Single |
| 00325418749 | ZIMMERMAN | MARY | 08/01/2005 | Single |
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