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This document shows monthly premium contributions for a health insurance plan member named Niza Mae Ananayo Gobway with a social security number of 01-2113022-8 and date of birth of November 21, 1990. It displays the premium amounts contributed each month from September 2012 through November 2012, totaling 3,068.
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- 1. Contributions - Actual Premiums SS Number 01-2113022-8 Member Name GOBWAY, NIZA MAE ANANAYO Date of Birth 11-21-1990 Date of Coverage 07-2012 Monthly Premiums Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,144.00 988.00 936.00 0.00 Summary (A) Total Number of Contributions Displayed 3 (B) Total Number of Contributions not Displayed 0 Total Number of Contributions Posted (A) + (B) 3 Total Amount of Contributions 3,068.00