| 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 |
| ADMINISTRATION ADJUSTMENTS |
|---|
Subscriber Update Information
The following changes have been made to our eligibility records.
*Action Code: 1=Addition, 2=Termination, 3=Eff Date Change, 4=Cov Type Change |
| Member Number | Member Last Name | Member First Name | Effective Date | *Action Code | Amount Due |
|---|
| 333456789 | STONE | KERWIN | 11/01/2006 | 1 | $ | 8.30 | |
| |
| Total Administration Adjustments: | $ | 8.30 | |
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