Welcome John Smith
ABC Company


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Policy:
 Billing Division:

Policy: 159159    Billing Division: 0001    Effective: 08/01/2004


ABC Company
1234 SE Main Street
Suite 100
Portland, OR 97204

Remittance Address:
STANDARD INSURANCE COMPANY
PO BOX 6367
PORTLAND, OR 97228-6367
USA

 

Premium Due Date:

Benefit Plan Rate Per  
BLIFE $0.235 $1000  
  LIVES INSURED AMOUNT Bill Category
Prior Figures:   2,228    22,280,000 0100
Actual Figures This Month:       
Totals and Adjustments: $0.16 $ $ $(99.84)
  Amount Due Back Charge Back Credit Total Amount Due
BAD&D $0.04 $1000  
  LIVES INSURED AMOUNT Bill Category
Prior Figures:   2,228    22,280,000 0100
Actual Figures This Month:       
Totals and Adjustments: $891.20 $ $ $791.20
  Amount Due Back Charge Back Credit Total Amount Due
DEPLF $0.65 Flat Premium  
  LIVES INSURED AMOUNT Bill Category
Prior Figures:   955    0100
Actual Figures This Month:       
Totals and Adjustments: $620.75 $ $ $620.75
  Amount Due Back Charge Back Credit Total Amount Due
  Benefit Premium Totals:
  Total Amount Due $ 1,312.11
  Total Billing Fees $ 0.00
  Amount to be Paid $ 1,312.11
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