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** Highlighted lines indicate that the premium amount being remitted was adjusted and/or a Change Request was submitted for the employee. <br />Worldwide Headquarters •Columbus, Georgia 31999 <br />1.800.99.AFLAC (1.800.992.3522) <br />aflac.com <br />Account Name: <br />Address: <br />Date Prepared:7/12/2014 <br />Billing Frequency:MONTHLY <br />Invoice Copy <br />7/30/2014 <br />CITY OF ARDEN HILLS <br />Attn Susan Iverson <br />1245 Highway 96 W <br />ARDEN HILLS, MN 55112-5743 <br />LEGEND <br />COVERAGE TYPE (CT) <br />I = Individual <br />F = Family <br />S = Single-Parent Family <br />P = Primary-Spouse <br />REMARKS (RM) <br />CV = Pending Conversion <br />PA = Policy is Paid Ahead <br />PC = Policy is Pending Conversion <br />and is Paid Ahead <br />CHANGE REQUEST (CR) <br />A=Add person to policy H = Name Change O = Other <br />C=Cancel Coverage I = Delete person from policy R = Retired <br />D=Deceased L = Non-Family Medical Leave T = No longer employed here <br />E=Unknown Insured-Remove M= Missed Deduction W= Transfer to another account <br />F=Family Medical Leave Y = Military Leave <br />Invoice Number:770777 <br />Account Number:G6L41 <br />Premium Due Date:8/1/2014 <br />Amount Billed:$327.92 <br />Amount Remitting:$327.92 <br />Billing Period:Jul 14 <br />Number of Deductions:2 <br />Deduction Frequency:24 <br />Billing Mode:MONTHLY <br />DUCK COPY - Submitted Invoice. Contains <br />reconciliation/changes made by <br />account. <br />Page 1 of 1 <br />The premium amount billed for some policies may not reflect the number of deductions indicated above if the <br />policies were issued during the billing period. <br />Policy Policy <br />Type CT Dept.Employee/ <br />Member #Name RM Premium <br />Due <br />Employee <br />Sub-Total <br />Adjusted <br />Premium <br />Adjusted <br />Sub-Total CR <br />P0F020Y8 ACC F DIETL, AMY $44.34 $44.34 $44.34 $44.34 <br />P0F020Z2 CANCER F EISENBRAUN, SHERRI $53.96 $53.96 <br />P0F020Z4 SPEVNT P EISENBRAUN, SHERRI $52.92 $106.88 $52.92 $106.88 <br />P0F020Y6 ACC P IVERSON KELLY, SUSAN $30.42 $30.42 <br />P0F020Z3 CANCER P IVERSON KELLY, SUSAN $53.96 $53.96 <br />P0F020Z5 SPEVNT P IVERSON KELLY, SUSAN $52.92 $137.30 $52.92 $137.30 <br />P0F020Z7 SPEVNT I KLINGBERG, SONJA $39.40 $39.40 $39.40 $39.40 <br />Total Amount Billed:$327.92 Amt Due $327.92