| 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 | |
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