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GROUP BILLING PREMIUM SUMMARY
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| Policy Number: 000001 |
Division Number: 00001 |
   Due Date: February, 2003
| Summary of current premiums for coverage from 02/01/2003 through 02/28/2003 |
| Class |
Dep
Cd |
# of Members |
# of Members
with Dependent
Coverage |
Member
Amount |
Dependent
Amount |
| 1 |
A |
3 |
0 |
72.60 |
.00 |
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B |
2 |
2 |
48.40 |
45.08 |
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C |
2 |
2 |
48.40 |
51.50 |
|
D |
3 |
3 |
72.60 |
144.87 |
| Total: |
|
10 |
7 |
242.00 |
241.45 |
Created on 03/19/03
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