- SUMMARY
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Annual Allocation: $500.00 Contribution $115.38 Current Balance: $40.38 Rollover: $50.00 Amount Remaining: $425.00 Pending Claims: $0.00 Claim Incurrence Period: 01/01/2015 - 03/15/2016 Enrollment Period: 01/01/2015 - 03/15/2016 Claim Cutoff Deadline: 01/01/2015 - 03/15/2016 - contributions
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Date Amount Description 01/05/2012 $115.38 Standard Contribution - reimbursement
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Date Type Amount Description 01/01/2015 Ck# 3679123 -75.00 Test Entry Updated - checks/direct deposit
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Type Number Date Amount . - forms
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- documents
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- rejections
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Service Date Scheduled Pay Date Amount Description 06/01/2015 Rejected 100.00 A rejected line item No Receipt Received - You must attach an itemized bill or explanation of benefits from your insurance carrier for healthcare expenses, please resend.
COBRA DetailsCURRENT PLAN YEAR (1/1/2015 - 12/31/2015)
Your Account Manager is @sAM
and may be reached at: 800.532.3327
Address: 1218 S Church St. Charlotte NC 28203