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April 28, 2025

My Invoices Invoice Summary Administration Adjustments Active Subscribers Claim Payment Information Recap by Sub Location Reconciliation of Account

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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
PRIOR DUE
No Prior Amount Due.
 
CURRENT DUE
 Total Administration Adjustments$8.30 
 Claim Payments 4,559.60 
 Current Administration Billed 348.60 
 Balance From Current Billing 4,916.50 
 
 Total Amount Due$4,916.50