Customer Name: ABC COMPANY
Invoice Number: 0002600234
Invoice Date: Oct 11, 2014
Billing Customer Number: 123456
Bill Group: 1
Coverage Period: 11/01/2014 – 11/30/2014
Due Date: Nov 01, 2014
Total Invoice Amount: $9,947.91
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Invoice Detail

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888888
Employee One
SEL+POS
*****1111-00
E
$457.69
Row count:  1
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The amounts listed on this invoice are based, in part, on the age and/or gender of each
covered employee and spouse (where applicable), and are provided solely for internal
billing purposes. You are solely responsible for establishing the contribution practices
for your employees. Federal, State, and local laws may prohibit you from charging
different contribution amounts based on an employee`s gender or other protected class
status.

To keep your group insurance coverage in effect, it is important that we receive full
payment of all amounts due, as required by your Group Contract/Policy. If your coverage
is terminated for non-payment of premium, this statement will serve as the required
initial advance notice of termination that will be effective in accordance with your
Group Contract/Policy at the end of your premium payment notification period.