Please enter the necessary information and select "Calculate" to view the results. You may then select "Print" at the bottom of the page to obtain a copy of this statement and mail it, along with your premium payment, to The Standard. This information will not be available after leaving this screen. Remit To Information Policy/Division Number: 001234560001 STANDARD INSURANCE COMPANY N1 Due Date: MM/DD/YYYY PO BOX 6367 PORTLAND , OR 97228-6367 Policyowner ABC COMPANY 1234 SE MAIN STREET PORTLAND, OR 97206   Category 0100 SHORT TERM DISABILITY - PER MEMBER RATE Lives Volume In Force Last Statement Add New Members Add Volume Increases   Less Terminated Members Less Volume Decreases   In Force This Statement 0 $0 Current Premium Rates Rate Varies Unadjusted Premium Add Back Charges Less Back Credits Adjusted Premium $0.00 Total Premium: $0.00

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