2

Premium Due Report Details

Effective

Policy effective date.

Policyholder

Policyholder name.

Policy No

Policy number.

Report Period

Period of time the report covers.

Line of Insurance

Line of insurance being reported.

1

Enrollment for tier 1 (single).

2

Enrollment for tier 2 (employee plus spouse).

3

Enrollment for tier 3 (employee plus children).

4

Enrollment for tier 4 (employee plus family).

Gross Premium

Premium before any deductions.

Amount Received

Premium received as of the reporting period.

Amount Applied

Premium applied as of the reporting period.

Overpayment

Any overpaid amounts as of the reporting period.

Balance Due

Premium due as of the reporting period.

Allocated

Date when allocations occurred.