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April 28, 2025

My Invoices Invoice Summary Reconciliation of Account

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Invoice Number:148348
Reconciliation Period:01/01/2007 - 01/31/2007

Master Number:03000-00
Description: 
Phone Number:(999) 999-0000

SELF INSURED SUMMARY
BENEFITS ADMINISTRATOR
321 UNIVERSITY AVENUE
ANYWHERE, USA 55555-0000
Group NumberBilled AmountClaimsOtherAdminTotal Due
93705-000-00000-00000$8,995.50 $4,559.60 $.00 $356.90 $4,916.50 
 
TOTALS:$8,995.50 $4,559.60 $.00 $356.90 $4,916.50 

 

Group NumberTotal SubsSelfFamily
93705-000-00000-00000832756
 
TOTALS:832756

 

RECONCILIATION OF ACCOUNT
Reconciliation Period: 01/01/2007 - 01/31/2007
Due Date: 02/10/2007

Prior Due
 Prior Amount Due$.00 
 Less Deposits Received 4,916.50 
 Balance Forward 4,916.50-
 
Current Due
 Total Administration Adjustments$8.30 
 Current Administration Billed 348.60 
 Claim Payments 4,559.60 
 Balance From Current Billing 4,916.50 
 
Total Amount Due
 Total Amount Due$.00 
     
 

Please make checks payable to: DELTA DENTAL

Payments and changes not reflected on this invoice will appear on the next invoice.

PLEASE RETURN THIS PAGE WITH YOUR PAYMENT.

Include the completed eligibility transmittal form if changes are to be made to enrollment. Retain all other documents for your records.

 
Group Name: SELF INSURED SUMMARY
Dental Group Number: 03000-00

Dental Amount Due: $ .00 
Dental Amount Submitted: $ ______________________________________

Signature:    ______________________________________

Please send all remittance to:
DELTA DENTAL
ASO BILLING
PO BOX 999
ANYWHERE USA 55555