Preview
FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023
"B"
EXHIBIT
FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023
UnitedHealthcare
UHS Premium Billing Manage your Account:
PO BOX 94017 WWW.employereservices.com
Palatine, IL 60094-4017 Invoice No: 046780823687
Invoice Date: 02/12/2020
Customer No: 08F3125
Bill Group No: 1
Coverage Period: 01/01/2020 - 02/29/2020
Due Date: 02/12/2020
BENDER CONTRACTING LLC
JAMES BENDER
5523 SHADY AVE
LOWVILLE NY 13367-1632
Account Summary Thank you for your business.
Previous Balance $14,206.04
Payments $0.00 About Your Payment
(-)
Account Adjustments (+/-) $0.00 We offer several payment options to help you manage your account.
Current Charges (+) $0.00
Pay Online. Go to www.employereservices.com to make a one-time payment
Current Adjustments (+/-) -$7,107.02 or schedule monthly payments directly from your bank account.
Other:
Fees/Credits $4.00 Pay By Phone. Call 1-888-842-4571, TTY 711, 8 a.m. -8 p.m. ET, Monday -
Friday, to make a payment directly from your bank account.
Total Balance Due $7,103.02 Pay By Check, Use the enclosed envelope to send us your payment. Your
payment must be sent to the address on the form below to ensure it is applied to
your account. Checks retumed for lack of funds or checks that can't be cashed for
any reason are not considered payment.
Payment is due in full on or before the due date above. If full payment la not
received by the end of your grace period, your coverage may be terminated
as stated In your policy requirements. if a premium payment Is deposited
late, It does not automatically mean we will accept the premium.
Please detach and return with y¬ur payment. 4
Customer Name Customer Number Payment Due Date Invoice #
BENDER CONTRACTING LLC 08F3125 02/12/2020 046780823687
Send payment to:
Minimum Amount Due: $7,103.02
UHS Premium Billing
PO BOX 94017
Palatine, IL 60094-4017 Amount Enclosed
I lmil lpl|p|lp|lilgll|¡lglpip|µpl
Ilphip ju||
046713692700100000007103020467808236877
FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023
CONTRACTING LLC Page 2 of 5
BENDER
Customer No: 08F3125
Invoice No: 046780823687
Invoice Date: 02/12/2020
Bill Group: 1
Coverage Period: 01/01/2020 - 02/29/2020
Due Date: 02/12/2020
Summary
Description Employee Total Volume Net Amount
Count
(000's)
Fees/Credits
Fee/Credit Description
Package Savings Credit $4.00
Subtotal, Fees/Credits $4.00
Adjustments
Account Adjustments $0.00
Current Adjustments -$7,107.02
Subtotal, Adjustrnents -$7,107.02
TOTAL 0 -$7,103.02
Questions? We re here10help
Totthee 1a88 842 457 wwwemployeeservicescom
FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023
Page 3 of 5
BENDER CONTRACTING LLC
Customer No: 08F3125
InvoiceNo: 046780823687
InvoiceDate: 02/12/2020
Bill Group: 1
Coverage Period: 01/01/2020 - 02/29/2020
Due Date: 02/12/2020
Details
CurrentDetail- 1/01-2/29/2020 AcQustmentDetail Totals
Policy Name Plan ID Coverage Status Voi Charge Period Code Amount Total
No. (000's) Amount
08F3125 BENDER,JAMES ADDby FlatAmount *"*'5343 E A 50 1/01-1/31/2020 TRM -51.00 -$4,44108
2/01-2/29/2020 TRM -$100
08F3125 BENDER,JAMES CHolCE/INS '""5343 ESC A 1/01-1/31/2020 TRM -$2,12770
2/01-2/29/2020 TRM -$2,12770
OBF3125 BENDER,JAMES DentalVPPO "*"5343 ESC A 1/01-1/31/2020 TRM -$7229
2/01-2/29/2020 TRM -$7229
08F3125 BENDER,JAMES Lifeby FlatAmount *"**5343 E A 50 1/01-1/31/2020 TRM -$650
2/01-2/29/2020 TRM -$650
OBF3125 BENDER,JAMES VisionVOLUNTARY "*"5343 ESC A 1/01-1/31/2020 TRM -$1305
2/01-2/29/2020 TRM -$1305
08F3125 PARRY,JOSHUA ADDby FlatAmount *""6154 E A 50 1/01-1/31/2020 TRM -$1.00 -52,665,94
2/01-2/29/2020 TRM -$1.00
08F3125 PARRY,JOSHUA CHOICE/lNS "*"6154 EC A 1/01-1/31/2020 TRM -$1,269.15
2/01-2/29/2020 TRM -$1,26915
08F3125 PARRY,JOSHUA DentalVPPO ""*6154 EC A 1/01-1/31/2020 TRM -$47.05
2/01-2/29/2020 TRM -$4705
08F3125 PARRY,JOSHUA Lifeby FlatAmount "*"6154 E A 50 1/01-1/31/2020 TRM -$650
2/01-2/29/2020 TRM -$650
08F3125 PARRY,JOSHUA VisionVOLUNTARY *""6154 EC A 1/01-1/31/2020 TRM -$927
2/01-2/29/2020 TRM -$9.27
08F3125 PackageSavingsCredit 1/01-1/31/2020 $2.00 $400
Coverage Type Status Code
E Employee Only A Active ADD Retroactive Addition
ES Employee and Spouse C Cobra TRM Retroactive Termination
ESC Employee and Family R Retiree CHG Retroactive Change
EC Employee and Child(ren) T Terminated
FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023
BENDER CONTRACTING LLC Page 4 of 5
Customer No: 08F3125
Invoice No: 046780823687
Invoice Date: 02/12/2020
Bill Group: 1
Coverage Period: 01/01/2020 - 02/29/2020
Due Date: 02/12/2020
Details
CurrentDetail" 141-2/29/2020 AsgustmentDetail Totals
Polley Name Plan ID Coverage Status Vol Charge Period
No. Code Amount Total
(000's) Amount
2/01-2/29/2020 $2.00
Total $0.00 47,103.02 47,103.02
Questions?
Wirei arerai &
Icilhe 1 ,88-842
46ii ewwemploy·:4e-::avirds
cro
FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320
NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023
BENDER LLC Page 5 of 5
CONTRACTING
Customer No: 08F3125
Invoice No: 046780823687
Invoice Date: 02/12/2020
Bill Group: 1
Coverage Period: 01/01/2020 - 02/29/2020
Due Date: 02/12/2020
About Your Bill Eligibility Changes
Employee and dependent information contained on this Please send all employee and dependent changes right
invoice is based on the most current information provided away so they can be included on your next invoice.
by you in your capacity as Plan Administrator to
Unimerica Life Insurance Company of New York, We are not able to process eligibility changes sent with
UnitedHealthcare Insurance Company of New York. your payment. Please visit www.employereservices.com
to update eligibility information.
Payment is due on or before
In full 02/12/2020. If full
For employers with employees IIving in Texas:
payment is not received by the end of your grace
as stated in Employers are responsible for premiums for employees
period, your coverage may be terminated
your policy requirements. For more Information who are no longer eligible for group coverage until the
please see your plan end of the month we are notified. For more information
about grace periods,
(for example: Policy). about Texas, go to www.employereservices.com.
documents Group
Your payment can take up to 10 days to post to your Please visit www.emolovereservices.com to
account. If we receive it after the Invoice Date, you'll see
make eligibility changes, view and pay your bill,
it in your next bill.
request paperiess billing, request health plan ID
cards and more!
Questions about your bill?
Call1-888-842-4571, TTY 711, 8 a.m. - 8 p.m. ET,
- Friday. Please have your billing customer
Monday
number and bill group number available when you call.
Underwritten by Unimerica Life Insurance Company of New York, UnitedHealthcare Insurance Company of New York
Questions? We re lee 10help
Io11hea I 888M2 4571 wwwemployeioseivicescom
Preview
FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320 NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023 "B" EXHIBIT FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320 NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023 UnitedHealthcare UHS Premium Billing Manage your Account: PO BOX 94017 WWW.employereservices.com Palatine, IL 60094-4017 Invoice No: 046780823687 Invoice Date: 02/12/2020 Customer No: 08F3125 Bill Group No: 1 Coverage Period: 01/01/2020 - 02/29/2020 Due Date: 02/12/2020 BENDER CONTRACTING LLC JAMES BENDER 5523 SHADY AVE LOWVILLE NY 13367-1632 Account Summary Thank you for your business. Previous Balance $14,206.04 Payments $0.00 About Your Payment (-) Account Adjustments (+/-) $0.00 We offer several payment options to help you manage your account. Current Charges (+) $0.00 Pay Online. Go to www.employereservices.com to make a one-time payment Current Adjustments (+/-) -$7,107.02 or schedule monthly payments directly from your bank account. Other: Fees/Credits $4.00 Pay By Phone. Call 1-888-842-4571, TTY 711, 8 a.m. -8 p.m. ET, Monday - Friday, to make a payment directly from your bank account. Total Balance Due $7,103.02 Pay By Check, Use the enclosed envelope to send us your payment. Your payment must be sent to the address on the form below to ensure it is applied to your account. Checks retumed for lack of funds or checks that can't be cashed for any reason are not considered payment. Payment is due in full on or before the due date above. If full payment la not received by the end of your grace period, your coverage may be terminated as stated In your policy requirements. if a premium payment Is deposited late, It does not automatically mean we will accept the premium. Please detach and return with y¬ur payment. 4 Customer Name Customer Number Payment Due Date Invoice # BENDER CONTRACTING LLC 08F3125 02/12/2020 046780823687 Send payment to: Minimum Amount Due: $7,103.02 UHS Premium Billing PO BOX 94017 Palatine, IL 60094-4017 Amount Enclosed I lmil lpl|p|lp|lilgll|¡lglpip|µpl Ilphip ju|| 046713692700100000007103020467808236877 FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320 NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023 CONTRACTING LLC Page 2 of 5 BENDER Customer No: 08F3125 Invoice No: 046780823687 Invoice Date: 02/12/2020 Bill Group: 1 Coverage Period: 01/01/2020 - 02/29/2020 Due Date: 02/12/2020 Summary Description Employee Total Volume Net Amount Count (000's) Fees/Credits Fee/Credit Description Package Savings Credit $4.00 Subtotal, Fees/Credits $4.00 Adjustments Account Adjustments $0.00 Current Adjustments -$7,107.02 Subtotal, Adjustrnents -$7,107.02 TOTAL 0 -$7,103.02 Questions? We re here10help Totthee 1a88 842 457 wwwemployeeservicescom FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320 NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023 Page 3 of 5 BENDER CONTRACTING LLC Customer No: 08F3125 InvoiceNo: 046780823687 InvoiceDate: 02/12/2020 Bill Group: 1 Coverage Period: 01/01/2020 - 02/29/2020 Due Date: 02/12/2020 Details CurrentDetail- 1/01-2/29/2020 AcQustmentDetail Totals Policy Name Plan ID Coverage Status Voi Charge Period Code Amount Total No. (000's) Amount 08F3125 BENDER,JAMES ADDby FlatAmount *"*'5343 E A 50 1/01-1/31/2020 TRM -51.00 -$4,44108 2/01-2/29/2020 TRM -$100 08F3125 BENDER,JAMES CHolCE/INS '""5343 ESC A 1/01-1/31/2020 TRM -$2,12770 2/01-2/29/2020 TRM -$2,12770 OBF3125 BENDER,JAMES DentalVPPO "*"5343 ESC A 1/01-1/31/2020 TRM -$7229 2/01-2/29/2020 TRM -$7229 08F3125 BENDER,JAMES Lifeby FlatAmount *"**5343 E A 50 1/01-1/31/2020 TRM -$650 2/01-2/29/2020 TRM -$650 OBF3125 BENDER,JAMES VisionVOLUNTARY "*"5343 ESC A 1/01-1/31/2020 TRM -$1305 2/01-2/29/2020 TRM -$1305 08F3125 PARRY,JOSHUA ADDby FlatAmount *""6154 E A 50 1/01-1/31/2020 TRM -$1.00 -52,665,94 2/01-2/29/2020 TRM -$1.00 08F3125 PARRY,JOSHUA CHOICE/lNS "*"6154 EC A 1/01-1/31/2020 TRM -$1,269.15 2/01-2/29/2020 TRM -$1,26915 08F3125 PARRY,JOSHUA DentalVPPO ""*6154 EC A 1/01-1/31/2020 TRM -$47.05 2/01-2/29/2020 TRM -$4705 08F3125 PARRY,JOSHUA Lifeby FlatAmount "*"6154 E A 50 1/01-1/31/2020 TRM -$650 2/01-2/29/2020 TRM -$650 08F3125 PARRY,JOSHUA VisionVOLUNTARY *""6154 EC A 1/01-1/31/2020 TRM -$927 2/01-2/29/2020 TRM -$9.27 08F3125 PackageSavingsCredit 1/01-1/31/2020 $2.00 $400 Coverage Type Status Code E Employee Only A Active ADD Retroactive Addition ES Employee and Spouse C Cobra TRM Retroactive Termination ESC Employee and Family R Retiree CHG Retroactive Change EC Employee and Child(ren) T Terminated FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320 NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023 BENDER CONTRACTING LLC Page 4 of 5 Customer No: 08F3125 Invoice No: 046780823687 Invoice Date: 02/12/2020 Bill Group: 1 Coverage Period: 01/01/2020 - 02/29/2020 Due Date: 02/12/2020 Details CurrentDetail" 141-2/29/2020 AsgustmentDetail Totals Polley Name Plan ID Coverage Status Vol Charge Period No. Code Amount Total (000's) Amount 2/01-2/29/2020 $2.00 Total $0.00 47,103.02 47,103.02 Questions? Wirei arerai & Icilhe 1 ,88-842 46ii ewwemploy·:4e-::avirds cro FILED: LEWIS COUNTY CLERK 09/15/2023 10:32 AM INDEX NO. EFCA2023-000320 NYSCEF DOC. NO. 3 RECEIVED NYSCEF: 09/15/2023 BENDER LLC Page 5 of 5 CONTRACTING Customer No: 08F3125 Invoice No: 046780823687 Invoice Date: 02/12/2020 Bill Group: 1 Coverage Period: 01/01/2020 - 02/29/2020 Due Date: 02/12/2020 About Your Bill Eligibility Changes Employee and dependent information contained on this Please send all employee and dependent changes right invoice is based on the most current information provided away so they can be included on your next invoice. by you in your capacity as Plan Administrator to Unimerica Life Insurance Company of New York, We are not able to process eligibility changes sent with UnitedHealthcare Insurance Company of New York. your payment. Please visit www.employereservices.com to update eligibility information. Payment is due on or before In full 02/12/2020. If full For employers with employees IIving in Texas: payment is not received by the end of your grace as stated in Employers are responsible for premiums for employees period, your coverage may be terminated your policy requirements. For more Information who are no longer eligible for group coverage until the please see your plan end of the month we are notified. For more information about grace periods, (for example: Policy). about Texas, go to www.employereservices.com. documents Group Your payment can take up to 10 days to post to your Please visit www.emolovereservices.com to account. If we receive it after the Invoice Date, you'll see make eligibility changes, view and pay your bill, it in your next bill. request paperiess billing, request health plan ID cards and more! Questions about your bill? Call1-888-842-4571, TTY 711, 8 a.m. - 8 p.m. ET, - Friday. Please have your billing customer Monday number and bill group number available when you call. Underwritten by Unimerica Life Insurance Company of New York, UnitedHealthcare Insurance Company of New York Questions? We re lee 10help Io11hea I 888M2 4571 wwwemployeioseivicescom