1993-09-01_GENERAL DOCUMENTS - C1981017

• Permit No: C1981017
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 9/1/1993
• Doc Name: Standard Life Insurance Company
• From: Mid-Continent Minerals Corporation
• To: Pitkin Iron Corporation
• Permit Index Doc Type: General Correspondence
• Media Type: D
• Archive: No

ft"WBI YLUUMW DIAIMMI fAwh 1
ACCOUNT NO. YQ30-100-6 COVERAGE PERIOD(d)i P.O. Box 16326
FROM 03-01-94 Columbus,Ohio 43216-6526
TO 04-01-94
DUE 03-01-94'
KOM PAYMENT CANCEL DATE 04-01-94 DATE BILLED 02-07-94
:• :.• :. :; : .. 2
. . . . .-:.•;. ....::';...:BILL:cLEsr< ':::�::::.':::. 04:::•. : ::: �oA BiLLixa
BILL CYCLE 7 CALL 1-614-464-3869
:.. ::•:..:; :.'': : •:.;:::.BILL.COMB:: '>:: `:: . :: :::: :':.`
PMIN IRON CORPORATION :•,>.. .. :: ; ::..::. . :: •::•i: .::::.. :::::>;::;::•.;;>;:;'•::< >i: :::::?;? >::;: :;: .:: '::>:::::•.; :'-.;:.:
P 0 BOX 38
CARS DALE CO 81623-003d::.•:. .. . .. :. :.. :.:...:::..:. ....•. :...•. .•. ..:.:
CONTRACT TYPE COLUMN LEGEND
1-0INDLE :' ' .. ::•::; ;`:' : : A-LATEST EFFECTIVE/CRANDH.DATE:: ::•G=LIFE PREMIUM :::::
?-MEDICARE COMP-BINDLE B-CONTRACT TYPE N-FBA FEES
.: •. 3-TNO PARTY'' :::::::::•`. C-BASE HEALTH PREMIUM'. ;<`;i;" ';;;••' : I-TPA FEES ".:.:
4-FAMILY D-DRUG PREMIUM J-ADMINISTRATIVE FEES
5-CERTIFICATEHOLDER/SPOUSE E-DENTAL PREMIUM .,:': : ... ;. :, :>: K=OTHER FEES
6-CERTIFICATEHOLDER/DEPENDENT(S) F-VIBION PREMIUM
7-CERTIFICATEROLDER/SPOUSE/DEPENDENTS `'.'..; ••' "
d-MIXED :.. .•... . .
DO NOT ADD NAMES
GROUP OTHER TOTAL
MEDICAL DRUG' DENT . '•VIB.'; LIFE FSA'::;:•. TPA:... •::• A80` ::::;??'::FE68;:;;::::MONTHLY PREMIUM
ERTIFICATE BOLDER I.D. NO. A d C D E F G B I J K PREMIUM DUE
LBERTN% CLYDE R 521-6040311 01-01-03 "1 141.04 if.4y 14.36 ;:":.::.. ':;::'.: - '::'.:.':::'';': '•'.'' . y'gAM•;:I.:•"l: q± :;`:174:84 :.': 174.84 COBRA EFFO;
AIR NADE A 323-98-14841 01-01-93 4 371.96 39.53 36.37 9.75 457.81 437.01
OLLINd BRUCE A 269.40-99791 •01-01-94 4 • 743.92= 7l.06•.73.14= :'.. ,::.:: ':`• :::::::,:':::'` :::{:: : ...`;: ::>:: :;: ';': : >:: :` :::::: >:'::
„•,,;,,8li.12 ARREARS
OBRA EFF120193 269-40-99791 01-01-94 1 141.04 19.44 190.48 160.48 COBRA EFF1:
OBRA EFF120193 269-40-99791 01-01-94 :: : • . ..282.08': 36.88. :?:;';:'::. .`::•: :.:::': :•:.;:'.: :. :..>: ::::':':.::::. ; :: Btd.96 ARREARS
•
ELANDEY DIANE D 324-64-32361 01-01-93 1 141.04 19.44 14.36 9.73 184.39 184.39
ELANBY ROB J 521-60.60624' 01-01-93 1 141.04" 19.44 14.36:. : :.:....... . :9.75 :' :,::;:::':` ;:: : :':' :':> '184:5l :184.5!
ARMUM JOHN E 521-52-63393 01-01-93 4 371.96 39.53 36.37 9.73 457.81 457.81
ORTUNB JIM 522.66-28019 : 01-01-93 ' 4 .371.96. .39.53 36.57 ..;>; ;::.::: ::;9.75 :: ::. :;•; ::;::::; :;i :;;::.:. 4a7.d1 ' :::.457.81
AB088I ROCKY 521-82-60992 01-01-93 4 371.96 39.33 36.57 9.73 457.61 437.81
EER " OILBER? M 461=30-10444 01-01-93 4 -.:. 371.96 371.96 39.53 : :'::::•::: ::. : >t::'411.49 411.49 COBRA EFF1(
ANICEK ALVIN F 506-50-91256 01-01-93 4 371.96 39.53 36.57 9.75 457.81 437.81
9.7s ::::: :::. ` aai.si 457.e1 : . .
CNILLIAMS ' TIMOTHY G 524-25-54016 01-01-93 .: 4 371.96 39.53 36.57 "'
CHOA DAVID 522-80-72338 01-01-93 4 371.96 39.53 36.37 9.75 457.81 457.81
NOMYSON LENIN R 323-52-86341•' 12-01-93 4 371.96 39.33 36.57 ; `:: 9.75 :: , . _ •• ,• .• •..::'.457.81'-:' 457.81
BOMPRON LENIN R 523-52-86341 12-01-93 1,115.88 118.39 1.09.71 29.23 10373.43 ARREARS
GROUP COPY
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