Interactive Demonstration - Employer Connection - Active Subscribers

November 7, 2025

My Invoices Invoice Summary Dental Subscriber Adjustments Dental Active Subscribers Statement of Account

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Invoice Number:	138355
Billing Period:	01/01/2007 - 01/31/2007

Dental Group Number:	20883-000-00000-28011
Group Name:	FULLY INSURED
Master Number:	00000
Description:
Phone Number:	(999) 999-0000

FULLY INSURED

100 MAIN STREET

ANYWHERE, USA 55555-0000

CURRENT PREMIUM BILLED
Number of Subscribers	Coverage Choice		Rate				Amount Due
6	Single	units at	$	35.36		per unit equals	$	212.16
21	S+Family	units at	$	101.32		per unit equals	$	2,127.72

						Current Billed:	$	2,339.88

ACTIVE SUBSCRIBERS
Member Number	Member Last Name	Member First Name	Coverage Type	Effective Date	Amount Due
00505050505	REICH	JOHN	Single	03/01/2005	$	35.36
00888888888	ROBERTS	BRUCE	S+Family	07/01/1985	$	101.32
00999999999	ROGERS	PATRICK	Single	09/01/2001	$	35.36
00101010101	RUIZ	FLORA	S+Family	02/01/2006	$	101.32
00202020202	RUNYON	PAULINE	S+Family	10/01/2005	$	101.32
00303030303	SCHNEIDER	HARVEY	S+Family	01/01/2002	$	101.32
00404040404	SMITH	DAVID	S+Family	08/01/1992	$	101.32
00333456789	STONE	KERWIN	S+Family	07/01/1985	$	101.32
00606060606	THOMPSON	EDWARD	S+Family	01/01/2007	$	101.32
00707070707	VANG	DAO	S+Family	07/01/1985	$	101.32
00808080808	VAUGN	DIANE	S+Family	03/01/2003	$	101.32
00909090909	VILLANUEVA	GUADALUPE	S+Family	07/01/2006	$	101.32
00111223333	VIZQUEL	ALEX	S+Family	12/01/1995	$	101.32
00222334444	VIZQUEL	OMAR	Single	03/01/2005	$	35.36
00111111111	VOLK	CHRISTINE	S+Family	01/01/2004	$	101.32
00333333333	WALKER	KYLE	S+Family	01/01/2007	$	101.32
00444444444	WARFIELD	LINDA	S+Family	07/01/1985	$	101.32
00555555555	WHITE	ELMER	S+Family	01/01/2007	$	101.32
00666666666	WHITNEY	NORBERT	S+Family	04/01/2001	$	101.32
00333445555	WINGER	FREDDY	S+Family	10/01/2004	$	101.32
00888991111	WINKELMAN	CINDY	Single	05/01/2000	$	35.36
00999112222	WINTERS	CONNIE	S+Family	10/01/2006	$	101.32
00333552222	WU	SHIGERU	S+Family	03/01/1995	$	101.32
00222114444	YANG	HOUA	S+Family	08/01/2004	$	101.32
00454123421	YOUNG	DONITA	Single	11/01/2005	$	35.36
00456789012	ZELLMER	JANET	S+Family	03/01/2003	$	101.32
00321324121	ZIMMERMAN	MARY	Single	01/01/1998	$	35.36

				Current Billed:	$	2,339.88

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