Exhibit_C3_-_July_2025_Premium_Statement.pdf

72 KB Posted

Attached to
RFP 25-05 Voluntary Critical Illness Plan (USI)
Solicitation number
0000036102
Issued by
San Bernardino County, San Bernardino City, California

About this file

Written by GovTribe AI ·

This document is a Critical Illness (CI) insurance premium statement from Standard Insurance Company for the Superior Court of California, County of San Bernardino for the billing period of July 1, 2025 to July 31, 2025. The policy (No. 160283 0002) covers 180 employees with a total insured amount of $4,805,000, with a current premium of $6,776.24. The statement includes detailed premium breakdowns for individual employees, showing variations in coverage levels and premium rates for employee-only (EE) and employee-plus-spouse (SP) tiers.

The total amount due for this billing cycle is $9,006.97, which includes a prior balance of $1,230.81 and premium adjustments of $999.92. The statement reveals nuanced premium changes for specific employees like Nicole Aguas and Lisa Howard, with monthly adjustments ranging from $0 to over $80 for different coverage tiers. The document provides a comprehensive view of the critical illness insurance coverage, showing individual employee insured amounts typically ranging from $10,000 to $30,000, with corresponding premiums varying based on coverage level and tier.

View the file

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This bill is regarding:

Critical Illness "CI"

Dear Policyholder, Thank you for choosing us to provide your employees with these important benefits. Attached is a summary of your latest bill for Policy No. 160283 0002 due 07/01/2025.

To pay your bill, follow these steps:

If you need to make member changes to your policy, please use your regular channel to submit those changes.

Did you know that you can sign up for paperless billing and pay online? If you're not already and wish to access your statement online or if you have any questions about your bill, please contact us at

(800) 634-1743.

Thank you.

Please complete and detach this coupon and return it with your check.

Superior Court of California, County of San Bernardino Attn: Benefits & Payroll Administrator

247 W THIRD STREET

SAN BERNARDINO, CA 92415

Review this statement for accuracy.

Fill out and detach the coupon.

Mail the completed coupon back to us with a check made payable to Standard Insurance Company.

Invoice Number:

Policy Number:

Due Date:

Total Due:

Amount Paid:

231225

07/01/2025 $9,006.97

160283 0002

Superior Court of California, County of San Bernardino Attn: Benefits & Payroll Administrator

247 W THIRD STREET

SAN BERNARDINO, CA 92415

Date Prepared: 06/16/2025

STANDARD INSURANCE COMPANY

PO BOX 5676

PORTLAND, OR 97228-5676

11001602830002000000000021250701000067762400009006970000023122500000167475

This page is intentionally left blank

Standard Insurance Company 160283 0002

Customer Service Contact:

(800) 634-1743

Date Prepared Invoice Number

06/16/2025 231225

Policy Number Due Date

160283 0002 07/01/2025

Billing Period

07/01/2025 - 07/31/2025

Coverage Member Count Insured Amount Current Premium

CI 180 4,805,000 $6,776.24

Total: $6,776.24

Amount Paid: -$16,440.75

Prior Balance (as of bill print date 06/16/2025): $1,230.81

Current Premium: $6,776.24

Premium Adjustments: $999.92

Other Adjustments: $0.00

Fees: $0.00

Total Due: $9,006.97

Remaining Credit: $0.00

Current Premium Member Detail

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

ABARCA, JOCELYNE XXX-XX-1235 CI - Enhanced/EE $20,000.00 $14.78 Total: $14.78

AGUAS, NICOLE XXX-XX-7079 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $10,000.00 $7.38 Total: $22.16

ALVARADO, MARIA XXX-XX-1218 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $40.16 Total: $62.32

AMES, LETICIA XXX-XX-1848 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $19.94 Total: $42.10

BALTIMORE, CYNTHIA XXX-XX-3737 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

BARNES, NADIA XXX-XX-9437 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

BERNAL, JACOB XXX-XX-6556 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

BERROSPE, EDEN XXX-XX-6843 CI - Enhanced/EE $10,000.00 $7.38

CI - Enhanced/SP $5,000.00 $3.70 Total: $11.08

BLANCO, MARITSA XXX-XX-7647 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $10,000.00 $7.38 Total: $22.16

BORGE, JEANNETTE XXX-XX-8354 CI - Enhanced/EE $10,000.00 $26.78 Total: $26.78

BORS, E DANIEL XXX-XX-7445 CI - Enhanced/EE $10,000.00 $13.30

CI - Enhanced/SP $5,000.00 $13.38 Total: $26.68

BOUCHARD, AMBER XXX-XX-8731 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

BROWN, RHONDA XXX-XX-4499 CI - Enhanced/EE $30,000.00 $80.30 Total: $80.30

CACHOLA, LIZA XXX-XX-5776 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

CARDENAS, LUIS XXX-XX-5419 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

CARL, BETTY XXX-XX-7391 CI - Enhanced/EE $10,000.00 $13.30 Total: $13.30

CARRILLO, MICHELLE XXX-XX-8486 CI - Enhanced/EE $10,000.00 $13.30

CI - Enhanced/SP $5,000.00 $6.64 Total: $19.94

CARTER, MICHELLE XXX-XX-6535 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

CAZARES, LEILANI XXX-XX-9841 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

CHANDLER, ALYSIA XXX-XX-7419 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $11.08 Total: $33.24

CHISLEY, SONYA XXX-XX-0393 CI - Enhanced/EE $20,000.00 $53.54

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

Total: $53.54

CHIU, WILLIAM XXX-XX-2202 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

COLLIERKOSMATKA,

KRISTEN

XXX-XX-1741 CI - Enhanced/EE $30,000.00 $22.16

Total: $22.16

CORTES, CONNIE XXX-XX-7048 CI - Enhanced/EE $20,000.00 $26.58

CI - Enhanced/SP $10,000.00 $13.30 Total: $39.88

CORTES, JENNIFER XXX-XX-6179 CI - Enhanced/EE $10,000.00 $13.30 Total: $13.30

COWDRY, MICHELLE XXX-XX-4859 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

CROSS, ANITRA XXX-XX-3565 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

CRUZ, VERONICA XXX-XX-0604 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

CULBERSON, AJA XXX-XX-6387 CI - Enhanced/EE $20,000.00 $26.58

CI - Enhanced/SP $10,000.00 $13.30 Total: $39.88

CURIEL, ALFONSO XXX-XX-1981 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

CURL, LISA XXX-XX-2242 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

DELAIR, ADRIENNE XXX-XX-9372 CI - Enhanced/EE $20,000.00 $26.58 Total: $26.58

DELATORRE, CASSANDRA XXX-XX-8971 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

DIAZMORA, CASSANDRA XXX-XX-6563 CI - Enhanced/EE $20,000.00 $8.12 Total: $8.12

DOMINGUEZ, CELINA XXX-XX-1981 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

DONALDSON, MARK XXX-XX-1380 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

DUFFER, HEATHER XXX-XX-3883 CI - Enhanced/EE $20,000.00 $26.58 Total: $26.58

DUNCAN, JONATHAN XXX-XX-9435 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

EISLER, KRISTINE XXX-XX-7085 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

EUBANKS, AMY XXX-XX-3249 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

EVANS, WILLIAM XXX-XX-2120 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $11.08 Total: $33.24

FARMER, CALANDRA XXX-XX-8787 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

FATA, NUMIA XXX-XX-9688 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

FEDERICO, JULIE XXX-XX-5974 CI - Enhanced/EE $10,000.00 $48.84 Total: $48.84

FLORES, DELIA XXX-XX-7952 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $11.08 Total: $33.24

FLORES, SILVIA XXX-XX-4747 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $19.94 Total: $42.10

FOK, EDNA XXX-XX-6933 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

FONTANA, JACQUELINE XXX-XX-2236 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $40.16 Total: $80.04

FOSTER, VALERIE XXX-XX-8853 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

FRYE, TONYA XXX-XX-3214 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

GAITAN, GERALD XXX-XX-5640 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

GAITAN, ROSANNA XXX-XX-1885 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

GALLEGOS, ERIK XXX-XX-4011 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

GARCIA, CYNTHIA XXX-XX-8604 CI - Enhanced/EE $10,000.00 $13.30

CI - Enhanced/SP $10,000.00 $26.78 Total: $40.08

GARCIA, VANESSA XXX-XX-6687 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $15,000.00 $6.10 Total: $20.88

GARDNER, KRYSTA XXX-XX-5756 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

GOMEZ, CLAUDIA XXX-XX-7481 CI - Enhanced/EE $10,000.00 $26.78 Total: $26.78

GONZALES, JESSE XXX-XX-6243 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

GONZALEZ-LOPEZ, FABIOLA XXX-XX-5735 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

GRAHAM, TAWNY XXX-XX-2462 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $10,000.00 $7.38 Total: $22.16

GRANADO, BERNADETTE XXX-XX-2610 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $10,000.00 $26.78 Total: $66.66

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

GRIEGO, MONICA XXX-XX-2336 CI - Enhanced/EE $10,000.00 $13.30

CI - Enhanced/SP $5,000.00 $6.64 Total: $19.94

GRISMORE, CHARMAINE XXX-XX-7585 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

GUERRERO, PATRICIA XXX-XX-1552 CI - Enhanced/EE $10,000.00 $7.38

CI - Enhanced/SP $10,000.00 $7.38 Total: $14.76

GUTIERREZ, BRIAN XXX-XX-3870 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

GUTIERREZ, VALERIE XXX-XX-1988 CI - Enhanced/EE $30,000.00 $80.30 Total: $80.30

HAJDUK, AMY XXX-XX-1511 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

HALL, KIMBERLY XXX-XX-2370 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

HARRIS, LORETTA XXX-XX-9716 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $73.24 Total: $153.54

HARTRANFT, ANDREA XXX-XX-5045 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $19.94 Total: $42.10

HELLERUD, WESLEY XXX-XX-1440 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

HENDRIX, LEISHA XXX-XX-9505 CI - Enhanced/EE $30,000.00 $146.50 Total: $146.50

HERNANDEZ, CHRISTIAN XXX-XX-0296 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $10,000.00 $7.38 Total: $22.16

HERNANDEZ, DEVINE XXX-XX-4525 CI - Enhanced/EE $30,000.00 $12.18 Total: $12.18

HERNANDEZ, ESPERANZA XXX-XX-7039 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

HERNANDEZ, MARLENE XXX-XX-7685 CI - Enhanced/EE $10,000.00 $13.30

CI - Enhanced/SP $10,000.00 $13.30 Total: $26.60

HILL, JESSICA XXX-XX-0992 CI - Enhanced/EE $20,000.00 $14.78 Total: $14.78

HINOJOSA, JANET XXX-XX-9415 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $19.94 Total: $42.10

HIRST, TANYA XXX-XX-2859 CI - Enhanced/EE $10,000.00 $13.30 Total: $13.30

HOWARD, LISA XXX-XX-1277 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $19.94 Total: $100.24

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

HUNLEY, LONI XXX-XX-3664 CI - Enhanced/EE $10,000.00 $26.78

CI - Enhanced/SP $10,000.00 $26.78 Total: $53.56

INCIONG, CHYRILL XXX-XX-1740 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

JIMENEZ, EDUARDO XXX-XX-5677 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $11.08 Total: $33.24

JOSEPH, LEVORA XXX-XX-2821 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

JOYEUX, MAKEDA XXX-XX-9505 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

JUNKER, CHRISTINE XXX-XX-7141 CI - Enhanced/EE $10,000.00 $13.30

CI - Enhanced/SP $5,000.00 $13.38 Total: $26.68

KAPPOS, WHITNEY XXX-XX-1068 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $10,000.00 $13.30 Total: $28.08

KEENE, STACY XXX-XX-8683 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

KONITZER, VIRGINIA XXX-XX-7062 CI - Enhanced/EE $10,000.00 $26.78

CI - Enhanced/SP $5,000.00 $13.38 Total: $40.16

LABAJO, CHRISTINA XXX-XX-4009 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $40.16 Total: $80.04

LAIRD, JESSICA XXX-XX-9636 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

LARRIGAN, WINIFREDA XXX-XX-8775 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $40.16 Total: $80.04

LE, DYLAN XXX-XX-5591 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

LOMELI, CARLA XXX-XX-4121 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

LOPEZ, EDITH XXX-XX-9449 CI - Enhanced/EE $30,000.00 $12.18 Total: $12.18

LOPEZ, SAMANTHA XXX-XX-5762 CI - Enhanced/EE $30,000.00 $12.18 Total: $12.18

LOPEZ-RIVERA, JOSEPHINE XXX-XX-5028 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

LOUGH, MICHAEL XXX-XX-0308 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

LUCERO, WENDY XXX-XX-0750 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

LUONG, GIAO XXX-XX-0272 CI - Enhanced/EE $20,000.00 $26.58 Total: $26.58

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

MALLORY, SHAYNA XXX-XX-7524 CI - Enhanced/EE $20,000.00 $14.78 Total: $14.78

MANIKAD, ANTINIE XXX-XX-6003 CI - Enhanced/EE $10,000.00 $7.38

CI - Enhanced/SP $5,000.00 $3.70 Total: $11.08

MARTINEZ, CRISTA XXX-XX-8266 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

MARTINEZ, JENNIFER A XXX-XX-9919 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

MARTINEZ, NICHOLAS XXX-XX-5054 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

MARTINEZ, OMAYRA XXX-XX-3000 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

MCCLAIN, CHRISTA XXX-XX-9855 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

MEDINA, VERONICA XXX-XX-6332 CI - Enhanced/EE $10,000.00 $13.30 Total: $13.30

MEDRANO, BARBARA XXX-XX-4472 CI - Enhanced/EE $20,000.00 $26.58

CI - Enhanced/SP $15,000.00 $11.08 Total: $37.66

MENDEZ, LIZETTE XXX-XX-9631 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

MENDOZA-ALVARADO,

MILDRED

XXX-XX-3893 CI - Enhanced/EE $10,000.00 $26.78

Total: $26.78

MICHEL, MIRELLA XXX-XX-8752 CI - Enhanced/EE $10,000.00 $13.30 Total: $13.30

MIMS-MUNOZ, TIFFANY XXX-XX-6189 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $19.94 Total: $42.10

MISHOE, SARAH XXX-XX-8523 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $11.08 Total: $50.96

MOLINA, AMALIA XXX-XX-3258 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

MONTES, ERIKA XXX-XX-9209 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $10,000.00 $13.30 Total: $28.08

MORALES, CECILIA XXX-XX-7914 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

MORENO, BRIANA XXX-XX-4114 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

MULLANEY, KATHLEEN XXX-XX-8302 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

NAREZ-ARMBRUSTER, JULIEXXX-XX-6954 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

NASCIMENTO, INEZ XXX-XX-2315 CI - Enhanced/EE $30,000.00 $12.18 Total: $12.18

NAVARETTE, KELLY XXX-XX-5236 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

NERI, BERENICE XXX-XX-4328 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $10,000.00 $13.30 Total: $28.08

OLVERA, ANDREA XXX-XX-5976 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $11.08 Total: $33.24

OROPEZA, MARIO XXX-XX-9574 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

ORTIZ, LAUREN XXX-XX-5222 CI - Enhanced/EE $10,000.00 $13.30

CI - Enhanced/SP $5,000.00 $6.64 Total: $19.94

OWENS, NICOLE XXX-XX-0843 CI - Enhanced/EE $20,000.00 $14.78 Total: $14.78

PATTERSON, NYCOLE XXX-XX-3638 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

PAYNE, RENA XXX-XX-3351 CI - Enhanced/EE $10,000.00 $26.78 Total: $26.78

PECH, LUBIA XXX-XX-0594 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

PEDROZA, JENNIFER XXX-XX-0824 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

PENA, RACHEL XXX-XX-0070 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

PEREZ, KIM XXX-XX-6274 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

PICKENS, LYLE XXX-XX-8144 CI - Enhanced/EE $10,000.00 $26.78 Total: $26.78

PIERCE, CLAUDIA XXX-XX-1838 CI - Enhanced/EE $20,000.00 $26.58

CI - Enhanced/SP $15,000.00 $19.94 Total: $46.52

QUEZADA, ALEXANNDRA XXX-XX-8707 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

REYES, VANESSA XXX-XX-1689 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

RIVERA, CERINA XXX-XX-5787 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $11.08 Total: $33.24

RODRIGUEZ, ALEXIS XXX-XX-4213 CI - Enhanced/EE $20,000.00 $8.12 Total: $8.12

RODRIGUEZ, ANDREA XXX-XX-0969 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $40.16 Total: $80.04

ROJAS, RAYMOND XXX-XX-6602 CI - Enhanced/EE $10,000.00 $4.06

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

Total: $4.06

ROMERO, JUANITA XXX-XX-7826 CI - Enhanced/EE $10,000.00 $26.78 Total: $26.78

SANDOVALPOLANCO,

MARIA

XXX-XX-4864 CI - Enhanced/EE $30,000.00 $39.88

Total: $39.88

SCHWARTZ, SHERRY XXX-XX-4802 CI - Enhanced/EE $30,000.00 $80.30 Total: $80.30

SCIORTINO, JOSHUA XXX-XX-2367 CI - Enhanced/EE $10,000.00 $13.30 Total: $13.30

SHEARER, JEANNETTE XXX-XX-4217 CI - Enhanced/EE $10,000.00 $26.78

CI - Enhanced/SP $10,000.00 $26.78 Total: $53.56

SHIPLEY, STACY XXX-XX-7621 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

SHIPMAN, CHRISTINE XXX-XX-1589 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

SOLIS, AMY XXX-XX-5854 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

SOLIS, ANA XXX-XX-1225 CI - Enhanced/EE $20,000.00 $14.78 Total: $14.78

SORIANOPEREZ, MIRIAM XXX-XX-2253 CI - Enhanced/EE $20,000.00 $8.12 Total: $8.12

STEPHENS, JACLYN XXX-XX-4697 CI - Enhanced/EE $10,000.00 $7.38

CI - Enhanced/SP $5,000.00 $3.70 Total: $11.08

STEWART, MICHELLE XXX-XX-3313 CI - Enhanced/EE $20,000.00 $53.54 Total: $53.54

STOPYAK, JACQUELINE XXX-XX-8806 CI - Enhanced/EE $30,000.00 $12.18 Total: $12.18

TAPIAWILSON, DELSA XXX-XX-2903 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

TAUFA, SITIVENI XXX-XX-3294 CI - Enhanced/EE $30,000.00 $22.16 Total: $22.16

TAYLOR, SAVANA XXX-XX-4663 CI - Enhanced/EE $20,000.00 $8.12

CI - Enhanced/SP $10,000.00 $7.38 Total: $15.50

TERRELL, ANGELIQUE XXX-XX-0864 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

TERRELL, BOBBY XXX-XX-7366 CI - Enhanced/EE $10,000.00 $13.30

CI - Enhanced/SP $5,000.00 $6.64 Total: $19.94

TORRES, SULMA XXX-XX-2829 CI - Enhanced/EE $20,000.00 $26.58

CI - Enhanced/SP $15,000.00 $19.94 Total: $46.52

URUENA, VALERIE XXX-XX-4073 CI - Enhanced/EE $20,000.00 $14.78

CI - Enhanced/SP $10,000.00 $7.38 Total: $22.16

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

VALADEZ, CLORINDA XXX-XX-7629 CI - Enhanced/EE $30,000.00 $80.30

CI - Enhanced/SP $15,000.00 $40.16 Total: $120.46

VALDES, CORINE XXX-XX-0043 CI - Enhanced/EE $10,000.00 $13.30 Total: $13.30

VELARDE, ANGELA XXX-XX-5805 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

VELAZQUEZ, SOFIA XXX-XX-8399 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

VIDAL, BONNEY XXX-XX-4610 CI - Enhanced/EE $10,000.00 $7.38 Total: $7.38

VILLAGRAN, JAMES XXX-XX-3354 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

VILLARREAL, ERIKA XXX-XX-4141 CI - Enhanced/EE $20,000.00 $26.58

CI - Enhanced/SP $10,000.00 $13.30 Total: $39.88

WALSH, MISTY XXX-XX-9816 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

WARNER, TERESA XXX-XX-5447 CI - Enhanced/EE $30,000.00 $80.30 Total: $80.30

WEILAND, GINA XXX-XX-9973 CI - Enhanced/EE $20,000.00 $53.54

CI - Enhanced/SP $10,000.00 $26.78 Total: $80.32

WELCH, MICHAEL XXX-XX-2829 CI - Enhanced/EE $30,000.00 $12.18 Total: $12.18

WESTBROOKS, JANA XXX-XX-1951 CI - Enhanced/EE $30,000.00 $39.88 Total: $39.88

WHITE, LAURA XXX-XX-4769 CI - Enhanced/EE $30,000.00 $22.16

CI - Enhanced/SP $15,000.00 $11.08 Total: $33.24

WHITE-PENRIGHT,

MARYANN

XXX-XX-7315 CI - Enhanced/EE $20,000.00 $53.54

CI - Enhanced/SP $10,000.00 $26.78 Total: $80.32

WILKINSON, JASON XXX-XX-4355 CI - Enhanced/EE $30,000.00 $39.88

CI - Enhanced/SP $15,000.00 $19.94 Total: $59.82

WORTHAM, NEKESHA XXX-XX-1946 CI - Enhanced/EE $10,000.00 $13.30 Total: $13.30

YOON, HYUN XXX-XX-7159 CI - Enhanced/EE $20,000.00 $26.58

CI - Enhanced/SP $15,000.00 $11.08 Total: $37.66

ZAVALA, CECILIA XXX-XX-4196 CI - Enhanced/EE $10,000.00 $4.06 Total: $4.06

ZENZEN, SUSAN XXX-XX-1186 CI - Enhanced/EE $10,000.00 $26.78 Total: $26.78

Total: $6,776.24

Member Adjustments

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

Eff Date Adjustment Reason

AGUAS, NICOLE XXX-XX-7079 Premium Change06/01/2024CI - Enhanced/EE $20,000.0 $0.00

Premium Change06/01/2024CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change07/01/2024CI - Enhanced/EE $20,000.0 $0.00

Premium Change07/01/2024CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change08/01/2024CI - Enhanced/EE $20,000.0 $0.00

Premium Change08/01/2024CI - Enhanced/SP $10,000.0 -$5.55

Total: -$5.55

AGUAS, NICOLE XXX-XX-7079 Premium Change09/01/2024CI - Enhanced/EE $20,000.0 $0.00

Premium Change09/01/2024CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change10/01/2024CI - Enhanced/EE $20,000.0 $0.00

Premium Change10/01/2024CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change11/01/2024CI - Enhanced/EE $20,000.0 $0.00

Premium Change11/01/2024CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change12/01/2024CI - Enhanced/EE $20,000.0 $0.00

Premium Change12/01/2024CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change01/01/2025CI - Enhanced/EE $20,000.0 $0.00

Premium Change01/01/2025CI - Enhanced/SP $10,000.0 -$5.55

Total: -$5.55

AGUAS, NICOLE XXX-XX-7079 Premium Change02/01/2025CI - Enhanced/EE $20,000.0 $0.00

Premium Change02/01/2025CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change03/01/2025CI - Enhanced/EE $20,000.0 $0.00

Premium Change03/01/2025CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change04/01/2025CI - Enhanced/EE $20,000.0 $0.00

Premium Change04/01/2025CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change05/01/2025CI - Enhanced/EE $20,000.0 $0.00

Premium Change05/01/2025CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

AGUAS, NICOLE XXX-XX-7079 Premium Change06/01/2025CI - Enhanced/EE $20,000.0 $0.00

Premium Change06/01/2025CI - Enhanced/SP $10,000.0 -$3.70

Total: -$3.70

HOWARD, LISA XXX-XX-1277 Premium Change06/01/2024CI - Enhanced/EE $30,000.0 $53.52

Premium Change06/01/2024CI - Enhanced/SP $15,000.0 $6.64

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

Eff Date Adjustment Reason

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change07/01/2024CI - Enhanced/EE $30,000.0 $53.52

Premium Change07/01/2024CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change08/01/2024CI - Enhanced/EE $30,000.0 $80.28

Premium Change08/01/2024CI - Enhanced/SP $15,000.0 $9.96

Total: $90.24

HOWARD, LISA XXX-XX-1277 Premium Change09/01/2024CI - Enhanced/EE $30,000.0 $53.52

Premium Change09/01/2024CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change10/01/2024CI - Enhanced/EE $30,000.0 $53.52

Premium Change10/01/2024CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change11/01/2024CI - Enhanced/EE $30,000.0 $53.52

Premium Change11/01/2024CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change12/01/2024CI - Enhanced/EE $30,000.0 $53.52

Premium Change12/01/2024CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change01/01/2025CI - Enhanced/EE $30,000.0 $80.28

Premium Change01/01/2025CI - Enhanced/SP $15,000.0 $9.96

Total: $90.24

HOWARD, LISA XXX-XX-1277 Premium Change02/01/2025CI - Enhanced/EE $30,000.0 $53.52

Premium Change02/01/2025CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change03/01/2025CI - Enhanced/EE $30,000.0 $53.52

Premium Change03/01/2025CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change04/01/2025CI - Enhanced/EE $30,000.0 $53.52

Premium Change04/01/2025CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change05/01/2025CI - Enhanced/EE $30,000.0 $53.52

Premium Change05/01/2025CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

HOWARD, LISA XXX-XX-1277 Premium Change06/01/2025CI - Enhanced/EE $30,000.0 $53.52

Premium Change06/01/2025CI - Enhanced/SP $15,000.0 $6.64

Total: $60.16

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change06/01/2024CI - Enhanced/EE $30,000.0 $0.00

Premium Change06/01/2024CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

Eff Date Adjustment Reason

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change07/01/2024CI - Enhanced/EE $30,000.0 $0.00

Premium Change07/01/2024CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change08/01/2024CI - Enhanced/EE $30,000.0 $0.00

Premium Change08/01/2024CI - Enhanced/SP $15,000.0 $20.07

Total: $20.07

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change09/01/2024CI - Enhanced/EE $30,000.0 $0.00

Premium Change09/01/2024CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change10/01/2024CI - Enhanced/EE $30,000.0 $0.00

Premium Change10/01/2024CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change11/01/2024CI - Enhanced/EE $30,000.0 $0.00

Premium Change11/01/2024CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change12/01/2024CI - Enhanced/EE $30,000.0 $0.00

Premium Change12/01/2024CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change01/01/2025CI - Enhanced/EE $30,000.0 $0.00

Premium Change01/01/2025CI - Enhanced/SP $15,000.0 $20.07

Total: $20.07

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change02/01/2025CI - Enhanced/EE $30,000.0 $0.00

Premium Change02/01/2025CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change03/01/2025CI - Enhanced/EE $30,000.0 $0.00

Premium Change03/01/2025CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change04/01/2025CI - Enhanced/EE $30,000.0 $0.00

Premium Change04/01/2025CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change05/01/2025CI - Enhanced/EE $30,000.0 $0.00

Premium Change05/01/2025CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

LABAJO,

CHRISTINA

XXX-XX-4009 Premium Change06/01/2025CI - Enhanced/EE $30,000.0 $0.00

Premium Change06/01/2025CI - Enhanced/SP $15,000.0 $13.38

Total: $13.38

0100 0100Billing Category

Member Member ID Coverage/Tier PremiumInsured Amt

Eff Date Adjustment Reason

URUENA, VALERIE XXX-XX-4073 Retro Addition06/01/2025CI - Enhanced/EE $20,000.0 $14.78

Retro Addition06/01/2025CI - Enhanced/SP $10,000.0 $7.38

Total: $22.16

Total: $999.92

File details come from the government source that posted it. Updated .