DATE PREMIUM STATEMENT POLICY NO.

DIVISION
AUG 22 2022 421617 1
FOR THE PERIOD SEPT 1 2022 TO SEPT 30 2022
PAGE 1

BELLEVILLE STARTER & ALTERNATOR

TAYLOR BLANCHARD
7 122 PARKS DR
BELLEVILLE ON K8N 0N5

CARRIED FORWARD AMOUNT 0.00

CURRENT CHARGES/CREDITS

MISCELLANEOUS 0.00
ADJUSTMENTS FOR PRIOR PERIOD(S) 637.20
CURRENT PERIOD 637.20
SUBTOTAL 1,274.40

TOTAL AMOUNT DUE SEPT 1 2022 1,274.40

THE ABOVE TOTAL AMOUNT DUE WILL BE WITHDRAWN FROM YOUR BANK ACCOUNT.

REPORT CONTAINS CONFIDENTIAL INFORMATION FOR PLAN ADMINISTRATION PURPOSES

ONLY.

HAMNA
 DATE BENEFIT PREMIUM SUMMARY POLICY NO. DIVISION
AUG 22 2022 421617 1
FOR SEPT 1 2022 TO SEPT 30 2022
PAGE 1

TOTAL MISC ADJ CURRENT

LIFE 80.00 0.00 40.00 40.00

AD&D 40.00 0.00 20.00 20.00

DEP LIFE 3.44 0.00 1.72 1.72

HEALTH 520.56 0.00 260.28 260.28

DENTAL 536.00 0.00 268.00 268.00

BENEFIT TOTAL 1,180.00 0.00 590.00 590.00

LEGEND ER - EMPLOYER EE - EMPLOYEE

* - CHANGE SINCE LAST STATEMENT
 DATE TAX SUMMARY POLICY NO. DIVISION
AUG 22 2022 421617 1
FOR SEPT 1 2022 TO SEPT 30 2022
PAGE 1

SALES TAX ON 8.0000 % ER 72.52

EE 21.88
REGISTRATION # 12959 0774 TR0001 94.40

TOTAL TAXES 94.40

 DATE ADJUSTMENTS FOR PRIOR PERIOD(S) POLICY NO. DIVISION
AUG 22 2022 421617 1
PROCESSED ON OR BEFORE AUG 22 2022
PAGE 1
TOTAL EE ER
BLANCHARD, TAYLOR ID# 2 CLASS # 1
PLAN CHANGE ADJUSTED FROM AUG 1 2022 FOR 1 STATEMENT PERIOD(S)
LIFE 10.00 10.00
AD&D 5.00 5.00
DEP LIFE 0.86 0.86
HEALTH 84.14 84.14
DENTAL 90.00 90.00
BENEFIT COST 190.00 15.86 174.14
SALES TAX 15.20 ON 1.27 ON 13.93
GST/HST
TOTAL COST 205.20 17.13 188.07
COOK, CANDICE ID# 4 CLASS # 1
PLAN CHANGE ADJUSTED FROM AUG 1 2022 FOR 1 STATEMENT PERIOD(S)
LIFE 10.00 10.00
AD&D 5.00 5.00
DEP LIFE 0.86 0.86
HEALTH 84.14 84.14
DENTAL 90.00 90.00
BENEFIT COST 190.00 15.86 174.14
SALES TAX 15.20 ON 1.27 ON 13.93
GST/HST
TOTAL COST 205.20 17.13 188.07
MASON, JOHN JAYDEN ID# 3 CLASS # 1
PLAN CHANGE ADJUSTED FROM AUG 1 2022 FOR 1 STATEMENT PERIOD(S)
LIFE 10.00 10.00
AD&D 5.00 5.00
HEALTH 46.00 37.50 8.50
DENTAL 44.00 44.00
BENEFIT COST 105.00 52.50 52.50
SALES TAX 8.40 ON 4.20 ON 4.20
GST/HST
TOTAL COST 113.40 56.70 56.70
ROLLINS, MIRANDA ID# 1 CLASS # 1
PLAN CHANGE ADJUSTED FROM AUG 1 2022 FOR 1 STATEMENT PERIOD(S)
LIFE 10.00 10.00
AD&D 5.00 5.00
HEALTH 46.00 37.50 8.50
DENTAL 44.00 44.00
BENEFIT COST 105.00 52.50 52.50
SALES TAX 8.40 ON 4.20 ON 4.20
GST/HST
TOTAL COST 113.40 56.70 56.70
 DATE ADJUSTMENTS FOR PRIOR PERIOD(S) - POLICY NO. DIVISION
AUG 22 2022 421617 1
TOTALS
PAGE 1
PROCESSED ON OR BEFORE AUG 22 2022

TOTAL EE ER

LIFE 40.00 40.00

AD&D 20.00 20.00
DEP LIFE 1.72 1.72
HEALTH 260.28 75.00 185.28
DENTAL 268.00 268.00
BENEFIT COST 590.00 136.72 453.28
SALES TAX 47.20 10.94 36.26
GST/HST
TOTAL COST 637.20 147.66 489.54
 DATE DETAILED INFORMATION POLICY NO. DIVISION
AUG 22 2022 421617 1
FOR CURRENT PERIOD
PAGE 1
FOR SEPT 1 2022 TO SEPT 30 2022
ID# CLASS COVERAGE TOTAL EE ER
* BLANCHARD, TAYLOR
2 1 LIFE 10000 10.00 10.00
AD&D 10000 5.00 5.00
DEP LIFE INCLUDED 0.86 0.86
HEALTH FAMILY 84.14 84.14
DENTAL FAMILY 90.00 90.00
BENEFIT COST 190.00 15.86 174.14
SALES TAX 15.20 ON 1.27 ON 13.93
GST/HST
TOTAL COST 205.20 17.13 188.07
* COOK, CANDICE
4 1 LIFE 10000 10.00 10.00
AD&D 10000 5.00 5.00
DEP LIFE INCLUDED 0.86 0.86
HEALTH FAMILY 84.14 84.14
DENTAL FAMILY 90.00 90.00
BENEFIT COST 190.00 15.86 174.14
SALES TAX 15.20 ON 1.27 ON 13.93
GST/HST
TOTAL COST 205.20 17.13 188.07
* MASON, JOHN JAYDEN
3 1 LIFE 10000 10.00 10.00
AD&D 10000 5.00 5.00
HEALTH SINGLE 46.00 37.50 8.50
DENTAL SINGLE 44.00 44.00
BENEFIT COST 105.00 52.50 52.50
SALES TAX 8.40 ON 4.20 ON 4.20
GST/HST
TOTAL COST 113.40 56.70 56.70
* ROLLINS, MIRANDA
1 1 LIFE 10000 10.00 10.00
AD&D 10000 5.00 5.00
HEALTH SINGLE 46.00 37.50 8.50
DENTAL SINGLE 44.00 44.00
BENEFIT COST 105.00 52.50 52.50
SALES TAX 8.40 ON 4.20 ON 4.20
GST/HST
TOTAL COST 113.40 56.70 56.70
 DATE DETAILED INFORMATION POLICY NO. DIVISION
AUG 22 2022 421617 1
FOR CURRENT PERIOD -
PAGE 1
TOTALS
FOR SEPT 1 2022 TO SEPT 30 2022

TOTAL EE ER

LIFE 40.00 40.00

AD&D 20.00 20.00
DEP LIFE 1.72 1.72
HEALTH 260.28 75.00 185.28
DENTAL 268.00 268.00
BENEFIT TOTAL 590.00 136.72 453.28
SALES TAX 47.20 10.94 36.26
GST/HST
TOTAL 637.20 147.66 489.54
 DATE DETAILED INFORMATION POLICY NO. DIVISION
AUG 22 2022 421617 1
FOR CURRENT PERIOD -
PAGE 1
COVERAGE VOLUME SUMMARY
FOR SEPT 1 2022 TO SEPT 30 2022

COVERAGE COVERAGE
VOLUME

LIFE 40,000
AD&D 40,000
HEALTH FAMILY 2
SINGLE 2
4
DENTAL FAMILY 2
SINGLE 2
4
 DATE CHANGE DETAIL REPORT POLICY NO. DIVISION
AUG 22 2022 421617 1
PROCESSED ON OR BEFORE AUG 22 2022
PAGE 1
ID# CLASS STMT TOTAL TOTAL EFFECTIVE BENEFIT COVERAGE CHANGE CODE
PERIOD PRIOR NEW DATE
START COST COST
DATE
BLANCHARD, TAYLOR
2 1 AUG 1 2022 205.20
AUG 1 2022 LIFE 10000 ADDITION
PLAN CHANGE
AD&D 10000 ADDITION
PLAN CHANGE
DEP LIFE INCLUDED ADDITION
PLAN CHANGE
HEALTH FAMILY ADDITION
PLAN CHANGE
DENTAL FAMILY ADDITION
PLAN CHANGE
COOK, CANDICE
4 1 AUG 1 2022 205.20
AUG 1 2022 LIFE 10000 ADDITION
PLAN CHANGE
AD&D 10000 ADDITION
PLAN CHANGE
DEP LIFE INCLUDED ADDITION
PLAN CHANGE
HEALTH FAMILY ADDITION
PLAN CHANGE
DENTAL FAMILY ADDITION
PLAN CHANGE
MASON, JOHN JAYDEN
3 1 AUG 1 2022 113.40
AUG 1 2022 LIFE 10000 ADDITION
PLAN CHANGE
AD&D 10000 ADDITION
PLAN CHANGE
HEALTH SINGLE ADDITION
PLAN CHANGE
DENTAL SINGLE ADDITION
PLAN CHANGE
ROLLINS, MIRANDA
1 1 AUG 1 2022 113.40
AUG 1 2022 LIFE 10000 ADDITION
PLAN CHANGE
AD&D 10000 ADDITION
PLAN CHANGE
HEALTH SINGLE ADDITION
PLAN CHANGE
DENTAL SINGLE ADDITION
PLAN CHANGE