| Invoice Number: | 142658 |
| Billing Period: | 01/01/2007 - 01/31/2007 |
| Vision Group Number: | 40001-000-00000-00000 |
| Group Name: | VISION |
| Master Number: | 40001 |
| Description: | |
| Phone Number: | (999) 999-0000 |
| VISION |
| GILLIAN MYERS |
| VP SECRETARY |
| 2245 BLUE JAY WAY |
| ANYWHERE, USA 55555-0000 |
| CURRENT PREMIUM BILLED |
|---|
| Number of Subscribers | Coverage Choice | Rate | Amount Due |
|---|
| 2 | Single | units at | $ | 9.72 | | per unit equals | $ | 19.44 | |
| 2 | S+Children | units at | $ | 21.38 | | per unit equals | $ | 42.76 | |
| |
| | Current Billed: | $ | 62.20 | |
| ACTIVE SUBSCRIBERS |
|---|
| Member Number | Member Last Name | Member First Name | Coverage Type | Effective Date | Amount Due |
|---|
| 00231524089 | ADAMS | SARAH | Single | 01/01/2007 | $ | 9.72 | |
| 00888888888 | ALBERTSON | BRENDA | S+Family | 07/01/1985 | $ | 21.38 | |
| 00999999999 | ALLEN | SALLY | Single | 09/01/2001 | $ | 9.72 | |
| 00101010101 | ALOMAR | MARIA | S+Family | 04/01/2006 | $ | 21.38 | |
| |
| | | | | Current Billed: | $ | 62.20 | |
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