| 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 | Basic Life | AD&D Amt | Vol Life | Vol Ad&D | Health | Dental | Premiums |
| 0000001 | Spade, S | 1 | 72,000 | 72,000 | 0 | 0 | Family | Family | 260.97 |
| 0000002 | Burns, B | 1 | 36,000 | 36,000 | 0 | 0 | Family | Single | 106.96 |
| 0000003 | Oakley, A | 1 | 100,000 | 100,000 | 0 | 0 | Single | Exempt | 67.70 |
| 0000004 | Long, L | 1 | 65,000 | 65,000 | 0 | 0 | Family | Family | 188.42 |
| 0000006 | Pitt, B | 1 | 36,000 | 36,000 | 0 | 0 | Single | Single | 97.44 |
| 0000007 | Bagley, J | 1 | 66,000 | 66,000 | 0 | 0 | Family | Single | 244.86 |
| 0000010 | Shoe, L | 2 | 125,000 | 125,000 | 0 | 0 | Single | Single | 118.56 |
| 0000011 | Hart, J | 2 | 125,000 | 125,000 | 0 | 0 | Single | Single | 118.96 |
| 0000012 | Rivers, R | 1 | 30,000 | 30,000 | 0 | 0 | Single | Single | 194.78 |
| 0000014 | White, B | 1 | 30,000 | 30,000 | 0 | 0 | Single | Single | 194.78 |
| 0000015 | Smith, J | 1 | 30,000 | 30,000 | 0 | 0 | Single | Single | 194.78 |
| 0000016 | Brown, B | 2 | 125,000 | 100,000 | 0 | 0 | Single | Single | 117.96 |
| 0000017 | Blister, B | 1 | 72,000 | 72,000 | 0 | 0 | Family | Family | 291.53 |
| 0000018 | Bond, J | 1 | 30,000 | 30,000 | 0 | 0 | Single | Single | 194.78 |
| Totals: | 14 Insureds | 942,000 | 917,000 | 0 | 0 | 14 | 13 | 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 |
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| 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 | ||