AFLAC VoucherVOUCHER
Date Voucher Number
V
E
N
D
O
R
APPROVED BY:
Invoice # Description Amount
Total:
Printed
for CITY OF BLAIR
CITY OF BLAIR
218 S 16TH ST
BLAIR NE 68008
12-31-2021 125195
AFLAC ACCT #LRA34 1932 WYNNTON RD COLUMBUS GA 31999
GL Account
687276 SVC AFLAC - GENERAL FUND 398.59
01-002-2421
687276 SVC AFLAC - STREET FUND 59.50
04-002-2421
687276 SVC AFLAC - WASTEWATER FUND 147.40
10-002-2421
687276 SVC AFLAC - WATER FUND 358.19
11-002-2421
963.68Vendor # 1035
1/07/2022 8:38:32
WORK IN PROGRESS - Invoice
Not Yet Submitted
Invoice Number:051086
Account Number:LRA34
Premium Due Date 02/15/2022
Amount Billed:$1212.82
Amount Remitting:$1072.78
Billing Period:January
Number of Deductions:2
Deduction Frequency:26
Billing Mode:MONTHLY
Worldwide Headquarters . Columbus, Georgia 31999
1.800.99.AFLAC (1.800.992.3522)
aflac.com
Invoice Copy
02/01/2022
Account Name:CITY OF BLAIR
Address:ATTN NATALIA SPRINGHOWER
218 S 16TH ST
BLAIR, NE 680082010
Date Prepared:01/26/2022
Billing Frequency:MONTHLY
** Highlighted lines indicate that the premium amount being remitted was adjusted and/or a Change Request was submitted for the employee.
The Premium amount billed for some policies may not reflect the number of deductions indicated above if the policies were issued during the billing period
Policy Policy
Type CT Dept.Employee/Member#Name RM Premium
Due
Employee
Sub-total
Adjusted
Premium
Adjusted
Sub-Total CR
P0S967L8 ACC F BACKMAN,
SARAH $48.00 $48.00
P0S967M7 STD I BACKMAN,
SARAH $38.64 $38.64
P0W2Z9R7 CANCER F BACKMAN,
SARAH $88.44 $88.44
P0Y8B625 HOSP F BACKMAN,
SARAH $94.80 $94.80 $ 269.88 $ 269.88
P0S967L4 STD I BARROW,
AARON $76.68 $76.68
P0S967M6 ACC F BARROW,
AARON $48.48 $48.48 $ 125.16 $ 125.16
P0S967L9 ACC I BEIERMANN,
JEFF $24.84 $24.84 $ 24.84 $ 24.84
P0S9A0J4 LIFE F BOSTWICK,
LUKE $34.92 $34.92
P0Y8K603 HOSP F BOSTWICK,
LUKE $105.12 $105.12 $ 140.04 $ 140.04
P0S9A0J6 LIFE I BOSTWICK,
LUKE $12.10 $12.10 $ 12.10 $ 12.10
P0S967C8 LIFE I COMBS, JEFF $48.18 $48.18
P0S979A3 ACC I COMBS, JEFF $28.56 $28.56 $ 76.74 $ 76.74
P0S9A6X5 ACC I GUTSCHOW,
BLAKE $31.44 $31.44 $ 31.44 $ 31.44
P0U0M2D3 ACC P JONES,
SHELLY $60.72 $60.72 $ 60.72 $ 60.72
P0U0S8D6 ACC I LONG,
PATRICK $24.84 $24.84 $ 24.84 $ 24.84
P0S967M1 HOSP F LUKERT,
WENDY $94.80 $94.80
P0S967M2 ACC F LUKERT,
WENDY
$69.36 $69.36
P0S967M8 CANCER F LUKERT,
WENDY $53.20 $53.20 $ 217.36 $ 217.36
P0V3M2C0 HOSP I RALEY,
JESSICA $51.72 T
P0V3M2T9 STD I RALEY,
JESSICA $88.32 $ 140.04 T
P0S9A6X6 ACC I WHEELER,
BRENDA $40.44 $40.44
P0Y8L836 CANCER S WHEELER,
BRENDA $49.22 $49.22 $ 89.66 $ 89.66
Total Amount Billed $1212.82 Amount
Due $1072.78
LEGEND
COVERAGE TYPE (CT)REMARKS (RM)CHANGE REQUEST (CR)
I = Individual
F = Family
S = Single-Parent Family
P = Primary-Spouse
CV = Pending Conversion
PA = Policy is Paid Ahead
PC = Policy is Pending Conversion and
is Paid Ahead
A = Add Spouse/Child H = Name Change O = Other
C = Cancel Coverage I = Delete person from
policy R = Retired
D = Deceased L = On Leave T = Insured Terminated/Left Employment
E = Never Employed
Here M = No Deduction Taken W = Transfer to another account
F = Family Medical
Leave Y = Military Leave
WORK IN PROGRESS - Invoice
Not Yet Submitted
Invoice Number:051086
Account Number:LRA34
Premium Due Date 02/15/2022
Amount Billed:$1212.82
Amount Remitting:$1072.78
Billing Period:January
Number of Deductions:2
Deduction Frequency:26
Billing Mode:MONTHLY
Worldwide Headquarters . Columbus, Georgia 31999
1.800.99.AFLAC (1.800.992.3522)
aflac.com
Invoice Copy
02/01/2022
Account Name:CITY OF BLAIR
Address:ATTN NATALIA SPRINGHOWER
218 S 16TH ST
BLAIR, NE 680082010
Date Prepared:01/26/2022
Billing Frequency:MONTHLY
** Highlighted lines indicate that the premium amount being remitted was adjusted and/or a Change Request was submitted for the employee.
The Premium amount billed for some policies may not reflect the number of deductions indicated above if the policies were issued during the billing period
Policy Policy
Type CT Dept.Employee/Member#Name RM Premium
Due
Employee
Sub-total
Adjusted
Premium
Adjusted
Sub-Total CR
P0S967L8 ACC F BACKMAN,
SARAH $48.00 $48.00
P0S967M7 STD I BACKMAN,
SARAH $38.64 $38.64
P0W2Z9R7 CANCER F BACKMAN,
SARAH $88.44 $88.44
P0Y8B625 HOSP F BACKMAN,
SARAH $94.80 $94.80 $ 269.88 $ 269.88
P0S967L4 STD I BARROW,
AARON $76.68 $76.68
P0S967M6 ACC F BARROW,
AARON $48.48 $48.48 $ 125.16 $ 125.16
P0S967L9 ACC I BEIERMANN,
JEFF $24.84 $24.84 $ 24.84 $ 24.84
P0S9A0J4 LIFE F BOSTWICK,
LUKE $34.92 $34.92
P0Y8K603 HOSP F BOSTWICK,
LUKE $105.12 $105.12 $ 140.04 $ 140.04
P0S9A0J6 LIFE I BOSTWICK,
LUKE $12.10 $12.10 $ 12.10 $ 12.10
P0S967C8 LIFE I COMBS, JEFF $48.18 $48.18
P0S979A3 ACC I COMBS, JEFF $28.56 $28.56 $ 76.74 $ 76.74
P0S9A6X5 ACC I GUTSCHOW,
BLAKE $31.44 $31.44 $ 31.44 $ 31.44
P0U0M2D3 ACC P JONES,
SHELLY $60.72 $60.72 $ 60.72 $ 60.72
P0U0S8D6 ACC I LONG,
PATRICK $24.84 $24.84 $ 24.84 $ 24.84
P0S967M1 HOSP F LUKERT,
WENDY $94.80 $94.80
P0S967M2 ACC F LUKERT,
WENDY
$69.36 $69.36
P0S967M8 CANCER F LUKERT,
WENDY $53.20 $53.20 $ 217.36 $ 217.36
P0V3M2C0 HOSP I RALEY,
JESSICA $51.72 T
P0V3M2T9 STD I RALEY,
JESSICA $88.32 $ 140.04 T
P0S9A6X6 ACC I WHEELER,
BRENDA $40.44 $40.44
P0Y8L836 CANCER S WHEELER,
BRENDA $49.22 $49.22 $ 89.66 $ 89.66
Total Amount Billed $1212.82 Amount
Due $1072.78
LEGEND
COVERAGE TYPE (CT)REMARKS (RM)CHANGE REQUEST (CR)
I = Individual
F = Family
S = Single-Parent Family
P = Primary-Spouse
CV = Pending Conversion
PA = Policy is Paid Ahead
PC = Policy is Pending Conversion and
is Paid Ahead
A = Add Spouse/Child H = Name Change O = Other
C = Cancel Coverage I = Delete person from
policy R = Retired
D = Deceased L = On Leave T = Insured Terminated/Left Employment
E = Never Employed
Here M = No Deduction Taken W = Transfer to another account
F = Family Medical
Leave Y = Military Leave