|
<br />AGE
<br />
<br />P-Cl0....U2
<br />
<br />EhlDP{:;'
<br />t'I'C.C"""J-il"'i;:::'
<br />'., i.-.!:i _, _.r,
<br />
<br />,~,'~:"7C GF;~DUP
<br />
<br />r:~;!t':lE
<br />
<br />A:,:::CDUi\iT j\UhEE;:,-
<br />
<br />,"-.:"i "iwi;
<br />.-.-... ..-
<br />! h...rH_ I;;
<br />
<br />r~CC;DUNT \"~Ul'/~E~;::F:;~ .-.
<br />
<br />{2jC:~:DU!\iT NUI'1E~E:F:-'
<br />
<br />P:C>:;UUNT \\n,.,!i'13:~F'"
<br />
<br />f~\CCDUt\jT ~\IU~""lDEF ...
<br />
<br />r..~..t[:.::. ;....~-:"'
<br />
<br />;\1 U j'~1 E t-:: F~
<br />
<br />t.:); [~;\5
<br />. 'w..' "'1..
<br />
<br />1 r....l.~~
<br />
<br />ACCJ~JN'rs PAYABL.E PRE-PAID CHEC.( REJISTER
<br />
<br />,-'., ;,!-'.;..'
<br />'.':1' .".
<br />
<br />UHit:.
<br />
<br />... ...-....-
<br />...... "...,..::.,
<br />. .. ,.. - . ... ..
<br />....: .. '.'::' .'.:
<br />.. -.. .. _. . ~.
<br />
<br />(:i!"1T"
<br />
<br />?~li''''IT '-.
<br />
<br />;:4!"j"'j'-
<br />
<br />r:-'il''''!T w.
<br />
<br />ACCrnJNT NUMEER- 100-419U-U4U000 RMj-
<br />ACCOtJNT NlJMBE:~- 100-42~,()""J4000() AMT..w
<br />
<br />A!"1'r...
<br />
<br />..' ._. .. ~.~. _ w.. _ .. _ ..
<br />~:~ / U .-...+ :1. :~:~u -. ::)':+{)(..:'::)U
<br />
<br />1. OO'-":"}::' ?C:'-O..:lOC(;(:;
<br />
<br />i (',(';.-..:1.1 ":!(';..w(\::'j.i"';("',(~{'i
<br />........... ,........... --' ,.........-.....
<br />
<br />1 OC, .... ...~!. :i. ::;0 .~. ~)4~)OC:G
<br />
<br />100.-. .'1- i. ;:;C:-<:)flUU()()
<br />
<br />l'''{C:~U~\IDS \.1 I E~~j
<br />
<br />11\1\.)D I Cf::
<br />
<br />11\1\/1] I CE [\.!r"iF{;:~.'
<br />
<br />DP!'1'E
<br />
<br />OJ. /0;:::/':'13
<br />
<br />.. i..!, 1;-" l' !-~r-
<br />i iC.j"./l.-' .:. i....f.:'_
<br />
<br />~~ j'''; [) U 1;..1 T
<br />
<br />'~'I!::--.,"'I '-.Ii:::'
<br />::.. '..} / :;' :; ;" .-'
<br />
<br />r"':~Jr~:'r'l."
<br />
<br />D I :::;~:::[!UNT
<br />
<br />f~,!''''iDU1\iT
<br />
<br />~!/!DUt\!T
<br />
<br />........ "
<br />:..: ..::'L -~: 1 ,1_.
<br />.n. ,.~.." .L. ....
<br />
<br />145r62 [[ES(~-~!EA!_TH Ii~S PREMIU~~-JANI.JARY
<br />
<br />,"-~,;;.:._'=:~} '"j'!:':::
<br />," '.... / ." " " '..'
<br />
<br />! ..:..:::...,..,.
<br />
<br />.--..... ...
<br />.. '-' ...-
<br />..... ......
<br />, .... ..-." "~.'
<br />
<br />....... . .....
<br />... ... . .
<br />..' .'" ..-..
<br />.-. . .. ...
<br />
<br />;JE:~:~~C '~'HEPlL TH I 1\~~3 F;:;:EI'ii I i..J!".!j.... '-l~.INU(~'!;;.y
<br />
<br />~jES(:-~!EALTH INS PREMIUM,w'~JANLJARY
<br />
<br />DES(::'-!~EAj_TH ll~~ F:'REMIljj~!,-,jANl.IARY
<br />
<br />Df~SC-HEAL'r'~i I~!S F'REMIUM..JANIJARY
<br />
<br />145~6S DESC:'-~~[~~LT!~ l~~:~ FlREMIiJM-'JANtJARY
<br />
<br />298~3i) DESC-HCAi..'Y'H INS F'REMIUM....JANlJPRY
<br />
<br />ACCOUNT NtJMBER- 100'-42()O-'O~.(:)(:)()O ~M'r- 3542~~~:3 JESC-'HEALr!~ INS P~~EMIUM--JANtJARY
<br />
<br />~fCC;DLII".JT
<br />
<br />ACCOUN-r NlJMBER- 1()O-4270-!)4.()~)OO AMT- ~=98~02 [!CSC....HEAL1.~~ INS PREMI!.JM'-JAN\JARY
<br />
<br />(\CCDU[\!!
<br />(,C::C:ClUNT
<br />
<br />,. I' I'..' :.~. r''''l-'.
<br />;\iijr\t.~t'.r~ .-.
<br />
<br />NUt"'jPEP-
<br />
<br />l\tU~';1BE::F~ .-.
<br />
<br />1 (::() ... 4 23() .~. ::)It()~})O
<br />
<br />100 ... 4:~~::;O"" <)!~.nn()n
<br />
<br />i nn.-..~.::::"\n._.cf..:::i.(i:.')(Jn
<br />.-.... ..-.... .........
<br />
<br />{:!I"iT -.
<br />
<br />{'1f''"!! -
<br />
<br />(~lC[:f]!Jt\~'l' l\iUf-ijBr.::~:..~ '700-. 4.1 :?O.~. C',.t~.()~)OO ;"~il:-5 i -
<br />
<br />At"'iT-
<br />
<br />P!CCCiUt\j'":"
<br />
<br />AC~COUNT NLJMBEl~'~' 700'~'41.2i-'040000 QM'T-
<br />
<br />ACCO(JN~ NIJM8EP'- 7'30'-41)().-i:14i)O()O AM'f-
<br />
<br />:2020 !'~lED I CP,
<br />
<br />f::~CCl]Ur",~ T
<br />
<br />f:'~iCC:DUf".JT
<br />
<br />{'~CCCU!\!T
<br />
<br />.:2~~j~:~~
<br />
<br />\\\1 ir.:i F{\=" F' .-.
<br />. .... .-........
<br />
<br />h.l: !r":iPj:":'~::.: ...
<br />I ..~_'\ ::_-:-_, '.
<br />
<br />j\!Ur~!E:j::F; .~.
<br />
<br />I\~ U r....! E E: F~.~ ..-
<br />
<br />!.....!L.~i\...iBEi::;~ ._.
<br />
<br />!\! U !''''i F E: F~ -~
<br />
<br />7:~::()""41:2 J. '-'C4~::~UOO
<br />
<br />.{-i.( :'{) .... l.~ c~ :i.
<br />
<br />i (';(':..- .d. i .-::,;...:.._(~t1.:":;~l!-~(':
<br />.:......_. ''':'.'.._' '._' ,'_"_"u"_'
<br />
<br />J.uo-:~ 1:.:::U.~.().q.c;::..l")()
<br />
<br />i 0 () ,- i!, :? G U ,., U .i:i, C<<\ U
<br />
<br />i ':)0 . .li. ::~(:O .-. ()4(:.U()()
<br />
<br />:? =:;..'() .~. .;"~. i ? 1 .- () !~. (';()()O
<br />
<br />2000 MEDCE:N'fERS }~!~AL.'T'H PLA*
<br />
<br />j::j c:: C U;,j !~.~ T ;',.j LJ \":1 E.: t: F\ .w.
<br />
<br />(~'!C::CDUr'..iT' !\iLJ!~1E';~::;':;.~".
<br />;~~ICC:DUN'T !\i.J!'~BEF~~ .--
<br />
<br />(iCCDUr~~ T NU1."1FEp....
<br />
<br />/, ......,~..-.:;=.
<br />
<br />1 UC; .-. 41 :~() -"()..lC:'C~)C
<br />
<br />1 00 .-./;.2UO.... ()/i.C=Uf)=:)
<br />
<br />........ .. - -. ............
<br />./ ::)U -...+ :t :.::: 1 -.. C;..:~.i.)UU':)
<br />
<br />7::;:;(::'-4:~ :;::~ 1....ULf.()OC;(::
<br />
<br />697() GROUP ~!EALTH PLAN1 IN1~
<br />
<br />(~iCCOI.JN-f
<br />
<br />f:'i [: C CJ tJ N T ;.....\ lJ ('J B E:. F~ .-
<br />P,CCiJu!\jT :\iU:":SEF'-
<br />
<br />".Ii 1;-...i1-,'-' ,.',
<br />r'.:, 'I"'''''.',-,.w.
<br />, "".~'" : .....,-.: .
<br />
<br />~~:)CCDU!':..IT
<br />
<br />;:\C;c;C;Ul'.jT i\j:..J!'1Ft::H ,.,
<br />P:CCDUi')T ~\~Ut"'iE'~E:I:;~-'
<br />
<br />1\IU!~iEE~~ -
<br />
<br />!~;CCDtJt'-.~T NU!"1E:EP'-'
<br />
<br />i:';CC;DU!\JT
<br />
<br />57(:)() COMMERIC~!_ LIF~E
<br />
<br />j\IU!\"IJjE.h~ .-
<br />
<br />r::~C:C:::DU(..IT
<br />
<br />~lccour'~T
<br />
<br />.~~;~;;~~::~
<br />
<br />r..i j ! (..~ }'~'1 ~~. ~:' .-
<br />"1'._'. 1"._':'._' '
<br />
<br />i\jUi'''!SEF: ,.,
<br />!\iur'lBf.-:::e ,.,
<br />!\:U:"!BEF-
<br />
<br />.:+()U ,I..:::,
<br />
<br />1 !:)()..~ 41. :~~C.- ~).,:.:. ~U~..~:..)
<br />
<br />~ :"';,''':..~ /1 'i ..)j-.:_/.i....J ...}(..:....,/"
<br />,i. ........J .T.L ..~,....' .......~,. .,;..'_.:1........'
<br />
<br />1 OO.....q.l ~=~O...::)4200U
<br />
<br />. ~ ~ .. - ... .......... ~
<br />]. ()U '"- .q. :iUC ..- U.q. :..:::~...;u::.)
<br />
<br />:~:~'?!O _. 41:21 ... ()';f 2()t)(:<
<br />
<br />)'C~G....i~. i 2C,-. U4::~~UCO
<br />
<br />7::::0....41?C ._.()i.j.200()
<br />
<br />i N~::;Ul:;~'~~'
<br />
<br />. .. ~ .. t)].
<br />
<br />2~? 0,- .q.l :?O .-. Ol:!.1. C()Ci
<br />
<br />........ ... w.. ........_
<br />'...::.:'~iU .~. ':{.l :,::~ 1 .... Ci .q. }. :)~)~)
<br />
<br />. .... ........ " -. -..-
<br />1 U().-::+ 1 ~:.~::)-'" ()i.j.l <:)()U
<br />
<br />. ... ....... ....... -..
<br />J ~)().- .q. 1 :.:~t) -.. ,:) .':';.1 U()~}
<br />
<br />i U()... 4 i :~~.;o .~- (".l\.1. ()C,O
<br />
<br />{~'!!'~'lT .-.
<br />
<br />;:'~! f"~ ~;-
<br />
<br />i\i.....!.'..
<br />
<br />f:':i ~~i i....
<br />
<br />1"; ~ . j ~
<br />
<br />(~.! /n:::::/'.:.)":;
<br />.. . . ... .. ...
<br />...... -.-. . .-
<br />
<br />i~:~ j'~; T .~.
<br />
<br />Hi"! i .-
<br />
<br />":y~ -
<br />
<br />... . _.~ . - .-
<br />f ':', /;': :._, ;~.. ; . ..:
<br />. .. .. . . - . .
<br />.-....., '-"-'/ .' '.-'
<br />
<br />P;!\"~'r ...
<br />
<br />Hr'~ i --
<br />
<br />Pt~T""
<br />
<br />?~r"': 1 '-.
<br />
<br />Fit",')T.-
<br />
<br />,~; r,,', i ..-
<br />
<br />!\!....j."f" ._
<br />
<br />""1'''' ,..
<br />: 1 . ..... ~ -, ".
<br />
<br />(::!t"'iT'"
<br />
<br />(2) ill" ,-
<br />
<br />(::~~'ll' ..-
<br />
<br />!~i!'tT'"
<br />Fir-',: ,.
<br />
<br />.-. .. - "...
<br />....,.: .:',
<br />.... ....
<br />.. ........ ...., 1
<br />. . .-. .. .... ...
<br />
<br />n. ._ _ _..
<br />.".:, '1:'.
<br />. .n _. ~ . _
<br />.. .: = " . ,~ .'
<br />...... _.. ... -
<br />
<br />D~.::3t:~'-'i-!Fqi!_ TH
<br />
<br />DE:3C'-HE:!~!L'rH
<br />
<br />DE::E;;C....HEPii_ T!...j
<br />
<br />.j. i'.,.._:
<br />
<br />T~~ F'RE\IUM-JANUARY
<br />
<br />F'FE17'! :i~ Uj'< .... ,Ji~I[\I! Jf!~~ Y'
<br />
<br />INS PREMIUM-JANUARY
<br />
<br />~?4...4~~ DESC'-HEAl._TH !I\!~ PRE.MIUM.-.JANUARY
<br />
<br />:~;9=~~. n bO DFE1C:--Hr~~:!LTH It\jf::; PFE:ri!Iu;.,:!._.~jt-)\IU(~!~-:;~Y
<br />
<br />..u. .d. .~~, =::J' ~~
<br />. : '~,' ,. , '....
<br />
<br />4)4.44 SEse-HEALTH INS PREMIUM-JANUARY
<br />
<br />9:=;7=:;-/.. 7:=:;
<br />. _. . ... ...
<br />
<br />.1,-,.-',
<br />
<br />.~. ;::;~7 " 1. .:':,
<br />
<br />.j ,...,..-:.. '\."
<br />. -.. ..-
<br />.... ...
<br />,L. ',~'" .., ... .....
<br />
<br />w. \:.. ..:
<br />. ~.. . .,.
<br />.... ."
<br />.:.'.-" ","'-.'
<br />
<br />.-,,"',,": ....,,....
<br />.' ~. .-'. '-."
<br />.,..... .-...,..-.....
<br />
<br />':'1 .:"
<br />, ..~... "w.
<br />.... .- ...
<br />...-. ...-...
<br />
<br />'!;; :"
<br />,....,...... ..:"
<br />.:. . '--:: , ....
<br />
<br />.,.::,::::..) ':',"1
<br />. . . ....
<br />. .. .... ..,
<br />-.~. .~ . ... "'
<br />
<br />.\ ,=\''', '1,:::-
<br />,.. -. . .
<br />. .-.' . .
<br />~. .... .: _L. '._'
<br />
<br />1.q.'}=1:~
<br />
<br />15.,24
<br />
<br />'1 ,--; .; .~':
<br />J. ,_, :: .!. '_'
<br />
<br />.i '_! ,. ....J '.~'
<br />
<br />-I':::' ......"
<br />= : = ,.....;.
<br />
<br />.. ''''
<br />i 1I / ......
<br />
<br />!:.-: ..'1 (~.,(':;
<br />'.-""'" ,"..'
<br />
<br />..:.~.~. " ":"'-.1
<br />
<br />..... .. ..' :"~I
<br />
<br />DE S~:: .-' HE Pit.. TH
<br />
<br />!)Fi\lDnt::~ TD'r~,L.
<br />
<br />.., ... - ..--
<br />, " ~ ':'d:': ,. ,
<br />. " ""~'" ~.. ".
<br />..' . ..... ...
<br />- ~.. .. -.. . -
<br />
<br />I~r::~:::~c w_ HE:{~'lL TH
<br />
<br />DLE;C -"j"'lEPd_ T1--I
<br />
<br />LE:~3C."HEP,LTH
<br />
<br />I.'IE:.~~~;C - HEP:L.'rH
<br />
<br />:CE~;C""HEP!LTH
<br />
<br />: ll''';'.:",'','-ii-'= ~,:-~~";-r,;
<br />..._. ... ..-. .......
<br />-..' =_.: .il_.'....;!.. ; =.~,: ; i-,:.._
<br />
<br />,) 1 /U::::/,):3
<br />
<br />;::!1:::: :::; C ,., ~.;r::,!~L T H
<br />UEf3C:'-~iEf~LTH
<br />
<br />iJE:~':;C ~.. HE(iL. 1"H
<br />
<br />DE:f.~;C""HEi~~lLTH
<br />
<br />\,iF~"..ji)C:;~::'~ 'rD"i' ~'!L
<br />
<br />u :t../O;::; ....i=:;'?
<br />
<br />.DC~:;C - D[::,\lT ~~~_
<br />
<br />DEE;C-" DEI"'~TI;L.
<br />
<br />C1F:~3C - DE~\JT PiL
<br />
<br />DE:~:~C - [iE::i\jT P:L
<br />
<br />,'-.1;,-;-'--:":", -...;:::.
<br />':'. , ... -;.. - ... . I
<br />. _. . .. . -
<br />
<br />!::'Hi::~l'i\~: ;.Jj-:J-. t.J~iJ\~U?:'i~~ '-.(
<br />
<br />T j\.iC~
<br />
<br />:1. 0.<:;.,::" =;:...{~.
<br />
<br />7,,;;-C
<br />; ,..,'-.
<br />
<br />FF;~E!I"!:r. Jt'l
<br />
<br />.! ,-, i;'" ,~', .';
<br />i '.,.""j'C' :: ::' .:~.
<br />
<br />~![:~il\lU(':F: y
<br />
<br />,J i:\ ~""! U (i S.' Y
<br />
<br />,J !~i ;....\ u ~~ll::;~ 'Y
<br />
<br />,..J(~\:\i Lh~f: Y
<br />".iP:!\i:..!(\F:Y
<br />
<br />" '..... ,':.'!
<br />.i. '..,.: '-'i'=::' " ~',.
<br />
<br />..-' .~ ... "'..
<br />,I :.:~ =::/ " U ()
<br />
<br />:._;?:i;\!~JPiF y
<br />
<br />J{:!,\!U{:iF~ y
<br />
<br />. .. . .. . -.-..
<br />,,J ~.~, r....j 1..3;:':: !...~ 't
<br />
<br />IJi:::1N~j~;f':;~ y
<br />
<br />7:::::9" O()
<br />
<br />- .. .-. .--
<br />:.:::.~./ u :.:::3
<br />
<br />. .. . .. . .. _. ..
<br />- ,.J(.'~ir'.itJ~:':!i"~ y
<br />
<br />:J~~ir".lUf~F;~ Y
<br />
<br />,Jf:!i\u?:\::;:-r
<br />
<br />DESC-DEN1'AL INS P0~E!1I\.JM .- JANl_1ARY
<br />
<br />,._;tl{\!Ui:'~H y
<br />
<br />T !",;;::.
<br />...j'.:...J
<br />
<br />'-',!-.I-~;,..;;'; !hl;
<br />T' :"',i::X:l;._;;'i -
<br />
<br />DES!~w.[!E~'l-AL. IN~:~ F'REMIUM JANUARY
<br />
<br />~ P.i~::}
<br />
<br />PF~t~:!71 I )j1'1
<br />
<br />l../EhIDC}F TDTr::1L.
<br />
<br />DESC._.DEN1'AL ~:\l~ F1RE~IL'M - JANt.!ARY
<br />
<br />247: = ::;:?
<br />
<br />~. ...~. ..-.~
<br />i ': ,: ;:~.; .. '..;' _'
<br />....' J. ,/ ....-.,_'.... ..' '_'
<br />
<br />UE:E~C .... L I FE
<br />
<br />DE~:)C -' 1... I F\:~
<br />
<br />DE3C-L. IF;;::
<br />
<br />Dl:~:::;C"~ L.. I Fe:::
<br />
<br />DE;3C-L.TI:'E
<br />
<br />:::h3
<br />
<br />:~'ri",;--h,l 7; ;;....:
<br />t. i"':d:'.i'i 1 :..},'1
<br />
<br />;;\:'.-'
<br />
<br />?FE!~1 I U~"i
<br />
<br />.;. r. l, i ,"',:1
<br />, '. . t..:. .'-. ~.. .c.>.
<br />....... ".-"'.' ,
<br />
<br />..:' :_.::,..: " ~J.:)
<br />
<br />j.:::j:;'i=tY!ll T ;'''!
<br />. l..'....' ,......4.',
<br />
<br />I r'..i~;
<br />
<br />F'f.~~EJ';'~U I 11:';
<br />
<br />; ~".; ~- .
<br />
<br />.- ... .-... .. ,.-. .
<br />;~"\-':r.:.FjU 1 f"'] .-.
<br />
<br />; [..j ~~.;
<br />
<br />FnEi''''iU I ["1
<br />
<br />._~ _. -' ....
<br />/:'::':/:, ()\)
<br />
<br />.- .. .-. ...-
<br />.,."1.. . ,.,
<br />..:,..:... -.-.
<br />.L._ : . '; ......_.
<br />
<br />I !\is
<br />
<br />Pi:;'r~7;'~1':'! i;'il
<br />, ,.1_= 1':"._', :
<br />
<br />T ,,!!....
<br />
<br />r)~~'~:.r~1 T i Jr.,i
<br />: :'. :~..: , ,~ '..-' \ ,
<br />
<br />.i.:'.;...-,
<br />
<br />I 1\1~1
<br />
<br />F;:~:E:;-~11 Ln':'1 -.
<br />
<br />~ l\i"-:
<br />
<br />FF\E~: I ty,!
<br />
<br />-. ..- .-..
<br />. ="" .:.,
<br />.... ~ ~
<br />..i... ..,. " ",.~,,_,
<br />
<br />-..- ... ...
<br />.. ... ...
<br />~ ... .. ...
<br />,_,; ._1 = '~:'_'
<br />
<br />I r',,!~? u F;~ {\ r',j C E:
<br />
<br />:=-F;Ej':
<br />
<br />:t \;~:~U~:;~~~NCE'=
<br />
<br />r-'i-':t:.P'i
<br />
<br />I {\I~::;UP(~lNCE
<br />
<br />FF~~E:r-:t
<br />
<br />I >JELir~~f:ll\ICE: PPj::'I.,..j
<br />
<br />I ~\~~3UF;~(~11\~L[ Pi~:r'j'~'! .-
<br />
<br />'1,'" ,....
<br />- ." . ....
<br />.. . -...
<br />._.... '._.' :1 '_' '~.'
<br />
<br />...... ... _.'
<br />-..-" .... ."
<br />- ...JHP"fLH"lK T
<br />
<br />, '\h I: ; .~, ,-,....
<br />- whl~l~Ji-ln ~
<br />
<br />.... ,Y'd",!U()::;~ y
<br />
<br />=.J~i!\!U!~iF~ y
<br />
<br />:.J~li\jU!:~}F=~ \'
<br />
|