7_EXHIBIT_B__Sample_Invoice.pdf
PDF 19 KB Posted
- Attached to
- BAGHDAD HEALTH INSURANCE
- Solicitation number
- SGE50015R0025
About this file
Exhibit B - Sample Invoice
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 2_SGE50015R0025.pdf | ||
| 4_Attachment_2_-_Prices_spreadsheet.xlsx | XLSX spreadsheet | |
| 5_Attachment_3_-_Experience.pdf | ||
| 1_Cover_Letter.pdf | ||
| 3_Attachment_1_-_Key_Personnel.pdf | ||
| 6_EXHIBIT_A_-_TCN_ _ORE.pdf | ||
| Pre_Sol_Notice _Baghdad_Health_Insurance.pdf |
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Text version
SGE50015R0025 Page 1 of 1
HEALTH INSURANCE, IRAQ
Exhibit B – Sample Invoice
Health Insurance
Contractor: John Doe, Inc.
Address: 9999 West Center Street Anywhere, USA XY 22222-1111
Invoice Date: 1-1-2016 Contract Number: SGE50015D00XX Customer: U.S. Embassy Description: Employee Health Insurance – Base Year (Option Year _____) Payment Terms: oooooooooooo Period of Performance Invoiced: From ____________ To: __________
Health Insurance
Employee name or ID#
Agency Bi-weekly premium Rate* medical & dental
# of bi-weekly pay periods
Total Joe Smith State 2.00 6 12.00 Pete Miller State 2.00 6 12.00 Diane Fuller State 2.00 6 12.00
Subtotal State 36.00
Fred Flint ORE 2.00 6 12.00 Bill Stone ORE 2.00 6 12.00 Megan Gray ORE 2.00 6 12.00
Subtotal ORE 36.00
* Health Insurance premium rate from the appropriate Section 1 paragraphs.
I hereby certify that the above bill is correct and in accordance with the terms of the contract and properly reflect insurance coverage and services performed.
Signature Title Date
Typed Name E-mail Address Phone Number
Please remit payment to: John Doe, Inc.
Account No 9999 Stay Safe Bank, Bank ID PKI95J300-52 Anywhere, USA 22222-1111
| Health Insurance |
| Payment Terms: oooooooooooo |
| Health Insurance |
File details come from the government source that posted it. Updated .