Interactive Demonstration - Employer Connection

November 7, 2025

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

Download
Customize & Download Statement (PDF) Download Statement (Excel) Download Eligibility Worksheet (PDF)

Invoice Number:	140979
Billing Period:	01/01/2007 - 01/31/2007

Dental Group Number:	03905-000-00005-00000
Vision Group Number:	40013-000-00000-00000
Group Name:	FULLY INSURED JOINT-BILLED
Master Number:	10302
Description:
Phone Number:	(999) 999-0000

FULLY INSURED JOINT-BILLED

JANE SINCLAIR

500 DIAMOND AVENUE

ANYWHERE, USA 55555-0000

CURRENT PREMIUM BILLED
Number of Subscribers	Coverage Choice		Rate			Amount Due
42	Single	units at	$	19.42	per unit equals	$	815.64
37	S+Family	units at	$	62.26	per unit equals	$	2,303.62

					Current Billed:	$	3,119.26

ACTIVE SUBSCRIBERS
Member Number	Member Last Name	Member First Name	Coverage Type	Effective Date	Amount Due
00989776543	AVERY	HEATHER	Single	07/01/2005	$	19.42
00213456789	BERG	DORIS	Single	08/01/2006	$	19.42
00652331254	BOONE	ROBERT	S+Family	07/01/2005	$	62.26
00456789012	BROWN	SHEILA	S+Family	07/01/2005	$	62.26
00652698745	CARLSON	DONALD	Single	07/01/2005	$	19.42
00262351208	CHASE	THOMAS	Single	07/01/2006	$	19.42
00642153297	COOPER	DUSTIN	Single	07/01/2005	$	19.42
00123456789	DETMER	CLARENCE	S+Family	05/29/2006	$	62.26
00654418897	DONALDSON	RYAN	Single	07/01/2006	$	19.42
00666778888	GARRISON	ALFRED	S+Family	07/01/2006	$	62.26
00909090909	GAUSS	PERRY	S+Family	07/01/2006	$	62.26
00232123152	GILBERT	BETH	S+Family	07/01/2006	$	62.26
00884562917	GILMORE	REBECCA	S+Family	07/01/2005	$	62.26
00332362514	GLAZA	PETER	Single	07/01/2006	$	19.42
00222114444	GONZALEZ	JESUS	S+Family	07/01/2005	$	62.26
00654241595	GREEN	LINDA	Single	07/01/2006	$	19.42
00113425697	GREENE	JANET	S+Family	07/01/2005	$	62.26
00652392687	GUNN	HILARY	Single	07/01/2005	$	19.42
00123456789	HAGEN	DEBRA	Single	07/01/2006	$	19.42
00114741259	HAMM	ANGELA	S+Family	07/01/2005	$	62.26
00505050505	HENESSEY	BRIAN	Single	07/01/2006	$	19.42
00325325652	HERMANN	STEVEN	Single	07/01/2005	$	19.42
00606060606	HEWITT	RAYMOND	S+Family	07/01/2005	$	62.26
00526134082	HOUSTON	PATRICIA	Single	07/01/2005	$	19.42
00999112222	HUGHES	LAURA	Single	07/01/2006	$	19.42
00707070707	HUNTINGTON	WENDY	S+Family	09/01/2006	$	62.26
00808080808	IVANSKI	ELAINE	Single	07/01/2006	$	19.42
00121134121	JOHNSON	KENNETH	S+Family	07/01/2006	$	62.26
00666666666	KELLER	LOUISE	S+Family	07/01/2006	$	62.26
00332133213	KEYSER	RENEE	S+Family	07/01/2005	$	62.26
00132459876	KHANG	PAO	S+Family	07/01/2006	$	62.26
00222334444	KNAPP	WILLIAM	Single	07/01/2005	$	19.42
00303030303	KOWALSKI	BRAD	Single	07/01/2005	$	19.42
00213056241	KRUEGER	MATTHEW	Single	07/01/2006	$	19.42
00774512398	LANG	JASON	Single	07/01/2005	$	19.42
00321456987	LARSON	BRANDON	Single	07/01/2006	$	19.42
00689565874	LEE	CRYSTAL	Single	07/01/2005	$	19.42
00111223333	LEWIS	SHAYNA	Single	07/01/2006	$	19.42
00654777149	MARKS	LYLE	S+Family	07/01/2005	$	62.26
00353562895	MARTINEZ	ANGELA	S+Family	07/01/2005	$	62.26
00333333333	MCDONALD	PAUL	Single	07/01/2006	$	19.42
00101010101	MCKINELY	HELEN	Single	07/01/2006	$	19.42
00265412564	MEAD	PHILLIP	Single	07/01/2006	$	19.42
00623541578	MILLER	STUART	S+Family	11/23/2005	$	62.26
00444556666	MORRIS	AMY	Single	07/01/2006	$	19.42
00542418975	OH	KIM	Single	07/01/2006	$	19.42
00653251298	OLSON	GLADYS	S+Family	07/01/2005	$	62.26
00541147485	PENNINGTON	CHARLES	S+Family	07/01/2006	$	62.26
00452154129	POOLE	RICHARD	Single	07/01/2005	$	19.42
00454123412	PORTER	ELIZABETH	Single	07/01/2005	$	19.42
00528419367	POWELL	TERRENCE	Single	07/01/2006	$	19.42
00123456789	PRATT	EARL	Single	07/01/2005	$	19.42
00555555555	RAMSEY	KERRI	Single	07/01/2006	$	19.42
00888888888	REICH	JOHN	S+Family	07/01/2005	$	62.26
00261749538	ROBERTS	BRUCE	S+Family	07/01/2006	$	62.26
00652398741	ROGERS	PATRICK	Single	07/01/2006	$	19.42
00111111111	RUIZ	FLORA	Single	07/01/2006	$	19.42
00555667777	RUNYON	PAULINE	S+Family	07/01/2005	$	62.26
00888991111	SCHNEIDER	HARVEY	S+Family	08/05/2006	$	62.26
00999999999	SMITH	DAVID	S+Family	08/21/2006	$	62.26
00333456789	STONE	KERWIN	Single	07/01/2005	$	19.42
00444444444	THOMPSON	EDWARD	Single	07/01/2006	$	19.42
00636251478	VANG	DAO	S+Family	07/01/2005	$	62.26
00992992541	VAUGN	DIANE	Single	07/01/2005	$	19.42
00333445555	VILLNUEVA	GUADALUPE	Single	07/01/2005	$	19.42
00321549876	VIZQUEL	ALEX	Single	07/01/2005	$	19.42
00626285945	VIZQUEL	OMAR	Single	07/01/2006	$	19.42
00404040404	VOLK	CHRISTINE	S+Family	07/01/2006	$	62.26
00565456485	WALKER	KYLE	S+Family	07/01/2006	$	62.26
00888991111	WARFIELD	LINDA	Single	07/01/2006	$	19.42
00999112222	WHITE	ELMER	S+Family	07/01/2006	$	62.26
00333552222	WHITNEY	NORBERT	S+Family	07/01/2005	$	62.26
00222114444	WINGER	FRED	S+Family	07/01/2006	$	62.26
00454123421	WINKELMAN	CINDY	S+Family	07/01/2006	$	62.26
00652987451	WINTERS	CONNIE	Single	07/01/2005	$	19.42
00231548970	WU	SHIGERA	Single	07/01/2006	$	19.42
00456789012	YANG	HOUA	S+Family	10/14/2006	$	62.26
00321324121	YOUNG	DONITA	S+Family	07/01/2005	$	62.26
00657444849	ZELLMER	JANET	S+Family	05/06/2006	$	62.26
00445464129	ZIMMERMAN	MARY	S+Family	04/14/2006	$	62.26

				Current Billed:	$	3,119.26