Sample Invoices

Monthly Supplemental Insurance Invoice

This is a sample Monthly Supplemental Insurance invoice, for new enrollments only.
invoice 9 page 001
1  -  Statement number ending in "MS" indicates this is a "Monthly Supplemental Insurance" invoice.
2  -  This shows the newly-enrolled member's name and the insurance item(s) being billed.
3  -  This is the total monthly insurance premium amount due for this listed member.

Monthly Insurance Adjustment Invoice

invoice 3 page 001
1  -  Statement number indicates this is a "M" or "Monthly" insurance invoice.
2  -  The coverage change being billed for.
3  -  This is the total monthly insurance premium amount due for this listed member.

TSA Supplemental Invoice

This TSA Supplemental Invoice is for a newly-enrolled member.
invoice 8 page 001
1  -  Statement number ending in "TS" indicates this is a "TSA Supplemental Bill."
2  -  This is the name of the newly-enrolled member.
3  -  This is the total TSA amount due for this newly-enrolled member.

Monthly Insurance Invoice

invoice 5 page 001


1  -  Statement number indicates this is a "M" or "Monthly" insurance invoice.
2  -  These are the insurance items being billed.
3  -  This is the total monthly insurance premium amount due for this listed member.

TSA Adjustment Invoice

This invoice is for a "Tax-Sheltered Annuity Contribution Adjustment." It must be requested by the employer.
invoice 1 page 001
1  -  Statement number ending in "TA" indicates this is a "Tax-Sheltered Annuity Adjustment" contribution invoice.
2  -  This is the TSA dollar amount due for this listed member based on the salary (dollar or percentage) change requested by the member.

TSA Contribution Invoice

This invoice is for a "Tax-Sheltered Annuity Contribution."

invoice 6 page 001



1  -  Statement number ending in "T" indicates this is a "Tax-Sheltered Annuity" contribution invoice.
2  -  This is the member listed on the TSA invoice.
3  -  This is the amount due for this listed individual member. The sum of all individual listed member amounts equals the total amount due.