TOTAL CLAIMS PAID DURING THE POLICY PERIOD $  Less Annual Aggregate Attachment Point $  Less Specific Claim Reimbursements Paid (provide details below) $  Less Specific Claims Pending (provide details below) $  Less Specific Claim Denials $  Less Beneifts Paid Outside the Self Funded Plan $  Adjustments (provide explanation below) $  AGGREGATE REIMBURSEMENT REQUESTED $

Details of Specific Claims (Paid and Pending): Name Date Total Amount

Other Adjustment Explanation:

N.B.

Submit a copy of your monthly paid claims listing which details all claims paid during the policy period. This report is produced each month and provides specific information about each payment made during the month. Types of information found on this report are employee name, claimant name, dates of service, provider name, amount charged, amount disallowed, amounts applied to co-insurance/deductibles, amount paid, check number, etc., for each individual payment made. Additionally, if not already forwarded, please send a copy of the Aggregate Stop Loss Monthly Report completed for the entire policy period. Upon Receipt of this information, we will notify you of the audit schedule.

COMPLETED BY:

Third Party Administrator: Phone Number: Contact Person: Date Completed: Address: E-Mail: