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GROUP BILLING ADJUSTMENT SUMMARY
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| Policy Number: 000001 |
Division Number: 00001 |
   Due Date: February, 2003
| Summary of current adjustments for coverage from 02/01/2003 through 02/28/2003 |
| Class |
Reason |
Amount |
Number of
Adjustments |
| 1 |
1 |
48.40 |
2 |
|
3 |
122.55 |
4 |
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4 |
-215.92 |
4 |
| Total: |
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-44.97 |
10 |
| Reasons: |
| 1 |
- |
Addition |
| 2 |
- |
Termination |
| 3 |
- |
Other Adjustment (+ Charge) |
| 4 |
- |
Other Adjustment (- Charge) |
Created on 03/19/03
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