| Group No 2 | Smith Transport Limited | Page 1 of 1 |
| Due Date 01 Jun 2005 | Group Insurance Premium Invoice | 17 Nov 2005 |
| Cert No | Name | Class | Life | Dep Life | AD&D | WI Amt | LTD Amt | Opt Life | Opt Ad&D | Health | Dental | Deductions | Premiums |
| 0000001 | Spade, S | 1 | 72,000 | 0 | 72,000 | 0.00 | 0.00 | 0 | 0 | Family | Family | ||
| $18.85 | $0.00 | $0.72 | $0.00 | $0.00 | $0.00 | $0.00 | $75.40 | $66.00 | $73.78 | $260.97 | |||
| 0000002 | Burns, B | 1 | 36,000 | 0 | 36,000 | 0.00 | 0.00 | 0 | 0 | Family | Single | ||
| $9.20 | $0.00 | $0.36 | $0.00 | $0.00 | $0.00 | $0.00 | $75.40 | $22.00 | $46.78 | $106.96 | |||
| 0000003 | Oakley, A | 1 | 100,000 | 0 | 100,000 | 0.00 | 0.00 | 0 | 0 | Single | Exempt | ||
| $25.40 | $0.00 | $1.00 | $0.00 | $0.00 | $0.00 | $0.00 | $41.30 | $0.00 | $28.70 | $67.70 | |||
| 0000004 | Long, L | 1 | 65,000 | 0 | 65,000 | 250.00 | 2,477.00 | 0 | 0 | Family | Family | ||
| $17.21 | $0.00 | $0.65 | $14.30 | $14.86 | $0.00 | $0.00 | $75.40 | $66.00 | $85.37 | $188.42 | |||
| 0000006 | Pitt, B | 1 | 36,000 | 0 | 36,000 | 250.00 | 1,510.00 | 0 | 0 | Single | Single | ||
| $10.42 | $0.00 | $0.36 | $14.30 | $9.06 | $0.00 | $0.00 | $41.30 | $22.00 | $41.42 | $97.44 | |||
| 0000007 | Bagley, J | 1 | 66,000 | 0 | 66,000 | 250.00 | 2,510.00 | 0 | 0 | Family | Single | ||
| $17.44 | $0.00 | $0.66 | $14.30 | $15.06 | $0.00 | $0.00 | $75.40 | $22.00 | $63.58 | $244.86 | |||
| 0000010 | Shoe, L | 2 | 125,000 | 0 | 125,000 | 250.00 | 1,410.00 | 0 | 0 | Single | Single | ||
| $31.25 | $0.00 | $1.25 | $14.30 | $8.46 | $0.00 | $0.00 | $41.30 | $22.00 | $51.99 | $118.56 | |||
| 0000011 | Hart, J | 2 | 125,000 | 0 | 125,000 | 250.00 | 1,477.00 | 0 | 0 | Single | Single | ||
| $31.25 | $0.00 | $1.25 | $14.30 | $8.86 | $0.00 | $0.00 | $41.30 | $22.00 | $52.19 | $118.96 | |||
| 0000012 | Rivers, R | 1 | 30,000 | 0 | 30,000 | 250.00 | 1,310.00 | 0 | 0 | Single | Single | ||
| $9.02 | $0.00 | $0.30 | $14.30 | $7.86 | $0.00 | $0.00 | $41.30 | $22.00 | $40.09 | $194.78 | |||
| 0000014 | White, B | 1 | 30,000 | 0 | 30,000 | 250.00 | 1,310.00 | 0 | 0 | Single | Single | ||
| $9.02 | $0.00 | $0.30 | $14.30 | $7.86 | $0.00 | $0.00 | $41.30 | $22.00 | $40.09 | $194.78 | |||
| 0000015 | Smith, J | 1 | 30,000 | 0 | 30,000 | 250.00 | 1,310.00 | 0 | 0 | Single | Single | ||
| $9.02 | $0.00 | $0.30 | $14.30 | $7.86 | $0.00 | $0.00 | $41.30 | $22.00 | $40.09 | $194.78 | |||
| 0000016 | Brown, B | 2 | 125,000 | 0 | 100,000 | 250.00 | 1,310.00 | 0 | 0 | Single | Single | ||
| $31.25 | $0.00 | $1.25 | $14.30 | $7.86 | $0.00 | $0.00 | $41.30 | $22.00 | $51.69 | $117.96 | |||
| 0000017 | Blister, B | 1 | 72,000 | 0 | 72,000 | 250.00 | 2,710.00 | 0 | 0 | Family | Family | ||
| $18.85 | $0.00 | $0.72 | $14.30 | $16.26 | $0.00 | $0.00 | $75.40 | $66.00 | $86.91 | $291.53 | |||
| 0000018 | Bond, J | 1 | 30,000 | 0 | 30,000 | 250.00 | 1,310.00 | 0 | 0 | Single | Single | ||
| $9.02 | $0.00 | $0.30 | $14.30 | $7.86 | $0.00 | $0.00 | $41.30 | $22.00 | $40.09 | $194.78 | |||
| Totals: | 0 | 14 Insureds | 942,000 | 0 | 917,000 | 2,750.00 | 18,644.00 | 0 | 0 | 14 | 13 | $742.77 | $2,392.48 |
| Cert No | Name | Retro-active Adjustments | Premiums |
| 0000001 | Spade, S | Salary Change Applied To Life Insurance Benefit May 1, 2005 | $5.27 |
| Salary Change Applied To A.d. & D. Benefit May 1, 2005 | $1.25 | ||
| Totals: | $6.52 |
|---|
| Group Insurance Invoice Summary for June 1, 2005 |
||
| Smith Transport Limited | Carried Forward From Last Statement | 2,659.39 |
| 1321 Brown's Line | Total Payments Received (thank you) | 0.00 |
| Toronto, Ontario | New Premium for the Current Month | 2,392.48 |
| Canada | Adjustments for the Current Month | 6.52 |
| L7B 1E6 | Outstanding Premium Now Due: | $5,058.39 |
| Please Remit Premiums to: Bishop Associates Incorporated, 170 Kingscross Drive, Unit Two, King City, Ontario, L7B 1E6, Telephone: (905) 833-4994 | ||