| 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 |
|---|
| 15 | Single | units at | $ | 5.60 | | per unit equals | $ | 84.00 | |
| 12 | S+Family | units at | $ | 14.21 | | per unit equals | $ | 170.52 | |
| |
| | Current Billed: | $ | 254.52 | |
| ACTIVE SUBSCRIBERS |
|---|
| Member Number | Member Last Name | Member First Name | Coverage Type | Effective Date | Amount Due |
|---|
| 00505050505 | RAMSEY | KERRI | Single | 07/01/2006 | $ | 5.60 | |
| 00888888888 | REICH | JOHN | Single | 08/01/2006 | $ | 5.60 | |
| 00999999999 | ROBERTS | BRUCE | S+Family | 07/01/2006 | $ | 14.21 | |
| 00101010101 | ROGERS | PATRICK | Single | 07/01/2006 | $ | 5.60 | |
| 00202020202 | RUIZ | FLORA | S+Family | 07/01/2006 | $ | 14.21 | |
| 00303030303 | RUNYON | PAULINE | S+Family | 07/01/2006 | $ | 14.21 | |
| 00404040404 | SCHNEIDER | HARVEY | S+Family | 07/01/2006 | $ | 14.21 | |
| 00333456789 | STONE | KERWIN | Single | 07/01/2006 | $ | 5.60 | |
| 00606060606 | THOMPSON | EDWARD | Single | 07/01/2006 | $ | 5.60 | |
| 00707070707 | VANG | DAO | Single | 08/01/2006 | $ | 5.60 | |
| 00808080808 | VAUGN | DIANE | Single | 07/01/2006 | $ | 5.60 | |
| 00909090909 | VILLANUEVA | GUADALUPE | S+Family | 07/01/2006 | $ | 14.21 | |
| 00111223333 | VIZQUEL | ALEX | Single | 07/01/2006 | $ | 5.60 | |
| 00222334444 | VIZQUEL | OMAR | Single | 07/01/2006 | $ | 5.60 | |
| 00111111111 | VOLK | CHRISTINE | Single | 07/17/2006 | $ | 5.60 | |
| 00333333333 | WALKER | KYLE | Single | 07/01/2006 | $ | 5.60 | |
| 00444444444 | WARFIELD | LINDA | Single | 07/01/2006 | $ | 5.60 | |
| 00555555555 | WHITE | ELMER | S+Family | 07/01/2006 | $ | 14.21 | |
| 00666666666 | WHITNEY | NORBERT | S+Family | 07/01/2006 | $ | 14.21 | |
| 00333445555 | WINGER | FRED | Single | 07/01/2006 | $ | 5.60 | |
| 00888991111 | WINKELMAN | CINDY | S+Family | 07/01/2006 | $ | 14.21 | |
| 00999112222 | WINTERS | CONNIE | S+Family | 07/01/2006 | $ | 14.21 | |
| 00333552222 | WU | SHIGERA | Single | 07/01/2006 | $ | 5.60 | |
| 00222114444 | YANG | HOUA | S+Family | 07/01/2006 | $ | 14.21 | |
| 00454123421 | YOUNG | DONITA | Single | 07/01/2006 | $ | 5.60 | |
| 00456789012 | ZELLMER | JANET | S+Family | 07/01/2006 | $ | 14.21 | |
| 00121324121 | ZIMMERMAN | MARY | S+Family | 07/01/2006 | $ | 14.21 | |
| |
| | | | | Current Billed: | $ | 254.52 | |
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