Policy: 00 123456-ABC Company Division: 0001-ABC 1 Billing Category: 0100
| STANDARD INSURANCE COMPANY RC ABC COMPANY 00 123456 0001
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| PO BOX 1234 ATTN JANE BROWN
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| PORTLAND OR 97228-5676 1234 SE MAIN STREET
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| PORTLAND 0R 97206
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| DEC. 16, 2005 JAN. 01, 2006
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| **** HELP US PROCESS YOUR PAYMENT ACCURATELY ****
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| PLEASE MAKE YOUR CHECK PAYABLE TO THE STANDARD AND RETURN TO US WITH
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| THE COUPON ADDRESS DISPLAYED IN THE ENCLOSED RETURN ENVELOPE.
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| LINE |
MEMBER ID |
NAME |
BILL CAT |
EFFECTIVE DATE |
BLIFE PREM |
BLIFE VOL |
AD&D PREM |
AD&D VOL |
PREMIUM DUE |
| 1 | 11122XXXX | ANDREWS, ALLISON | 0100 | 08/01/04 | 5.20 | 20,000 | 1.40 | 20,000 | 6.60 |
| 2 | 11133XXXX | AMES, SALLY | 0100 | 08/01/04 | 3.92 | 12,000 | 2.24 | 50,000 | 5.16 |
| 3 | 11144XXXX | BAKER, PAT G | 0100 | 08/01/04 | 9.60 | 35,000 | 1.70 | 35,000 | 11.30 |
| 4 | 11155XXXX | BARKER, JOE | 0100 | 08/01/04 | 19.12 | 57,000 | 2.74 | 57,000 | 21.86 |
| 5 | 11166XXXX | BOLTON, ED | 0100 | 08/01/04 | 4.56 | 16,000 | 1.32 | 16,000 | 5.88 |
| 6 | 11177XXXX | BUDD, JACK | 0100 | 08/01/04 | 4.98 | 18,000 | 1.36 | 18,000 | 6.34 |
| 7 | 11188XXXX | CARTER, DEB | 0100 | 08/01/04 | 5.20 | 20,000 | 1.40 | 20,000 | 6.60 |
| 8 | 11199XXXX | COLTON, DAVID E | 0100 | 08/01/04 | 38.68 | 123,000 | 5.78 | 123,000 | 44.46 |
| 9 | 11211XXXX | DAVIDSON, JEN R | 0100 | 08/01/04 | 17.36 | 46,000 | 2.07 | 46,000 | 19.43 |
| 10 | 11222XXXX | DAVIS, BOB S | 0100 | 07/01/05 | 4.56 | 16,000 | 1.32 | 16,000 | 5.88 |
| 11 | 11233XXXX | EVANS, ANN | 0100 | 08/01/04 | 4.40 | 15,000 | 1.30 | 15,000 | 5.70 |
| 12 | 11244XXXX | EWING, LISA C | 0100 | 11/01/05 | 7.00 | 25,000 | 1.50 | 25,000 | 8.50 |
| 13 | 11255XXXX | FADDEN, LOUISE M | 0100 | 07/01/05 | 5.45 | 21,000 | 1.42 | 21,000 | 6.87 |
| 14 | 11266XXXX | FANN, SARAH A | 0100 | 06/01/05 | 6.40 | 23,000 | 1.46 | 23,000 | 7.86 |
| 15 | 11277XXXX | FETTS, CATHY R | 0100 | 11/01/05 | 6.40 | 23,000 | 1.46 | 23,000 | 7.86 |
| 16 | 11288XXXX | FITTNER, JOHN S | 0100 | 12/01/05 | 5.45 | 21,000 | 1.42 | 21,000 | 6.87 |
| 17 | 11299XXXX | FOWLER, MARY | 0100 | 02/01/05 | 6.40 | 23,000 | 1.46 | 23,000 | 7.86 |
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| 18 | SUBTOTAL FOR BILLING CATEGORY 0100 | 185.03 |
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| STANDARD INSURANCE COMPANY RC (CONT) ABC COMPANY 00 123456 0001
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| PO BOX 1234 ATTN JANE BROWN
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| PORTLAND OR 97228-5676 1234 SE MAIN STREET
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| PORTLAND 0R 97206
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| DEC. 16, 2005 JAN. 01, 2006
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| 19 BLIFE 56 1765000 154.68 0 .00 TOTAL PREMIUMS 185.03
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| 20 AD&D 56 1765000 30.35 0 .00 TOTAL MEMBER ADJUSTMENTS 0.00
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| -----------
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| TOTAL THIS BILL 185.03
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| OUTSTANDING BAL AS OF 12/16/05 .00
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| PLEASE PAY THIS AMOUNT 185.03
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