201002032113070002TS1 Date Printed: 99/99/9999

201002032113070002TS1 Date Printed: 99/99/9999

UnitedHealthcare
Division: Benefit Services
P.O. Box 221709
Louisville, KY40252
Ph: (866) 747-0048 Fax: (866) 525-1740
CONTINUATION COVERAGE BILLING

{Participant Name}

{Participant Address}

{ParticipantCity, ST and Zip}

Include the remittancecouponon the reverse side for accurate processing

Carrier Name / Coverage / Coverage Dates / Amount / Due Date
Medical / PARTICIPANT ONLY / 03/01/2010 - 03/31/2010 / $ 548.76 / 99/99/9999
** ARRA Subsidy Amount / $ -356.69
Dental / PARTICIPANT ONLY / 03/01/2010 - 03/31/2010 / $ 39.78 / 99/99/9999
** ARRA Subsidy Amount / $ -25.86
Vision / PARTICIPANT ONLY / 03/01/2010 – 03/31/2010 / $ 5.66 / 99/99/9999
** ARRA Subsidy Amount / $ -3.68
Sub-Total / $ 207.97
Past Due / $0.00 / Due Immediately
Total / $207.97

Please pay close attention to your invoice. If you participated in the ARRA Subsidy program your 15 months of participation may be ending and you will be responsible for the full invoice amount. If you are participating in the EFT process the amounts will automatically adjust.

Note: To assure continued and uninterrupted coverage, you are responsible for making timely premium payments even if you do not receive monthly premium reminders. The past due amount can cause a suspensionor termination of coverage until the payment is received.

If you are set up to make payments through EFT directly from your checking or savings account, this billing notice is a just a reminder that the amount listed will be drafted from your account.

UnitedHealthcare is providing billing services for you under the {Client Name} group benefit plan(s). Enclosed is your remittance coupon, which reflects the premium due and payable for your coverage. In order to maintain eligibility under the group benefit plan(s), your payment must be received and postmarked no later than the coverage end date noted on each remittance coupon. Failure to remit payment prior to the coverage end date may result in a loss of coverage without the possibility of reinstatement. Your premium payment must be returned along with the remittance coupon for the payment period(s) you are paying. Please make your check payable to UnitedHealthcare. Detailed account information, payment information and electronic copies of mailings sent to you can be found on your account at

All Payments should be sent to: Or made online at
UnitedHealthcare
P.O. Box 713082
Cincinnati, OH 45271-3082

201002032113070002TS1

UnitedHealthcare offers you multiple options for making your payment;
1. Your premium payment must be returned along with the remittance coupon below for the payment period(s) you are paying. Please make your check payable to UnitedHealthcare and mail to the address below.
2. UnitedHealthcare offers you the option to make a one-time payment directly from your checking or savings account. To take advantage of this easy payment process, log on and click on the link to complete the information for your one time payment.

3. UnitedHealthcare offers you the ability to make payments through Electronic Funds Transfer (EFT) directly from your checking or savings account. Log-on to for more information. After signing into select Resources from the menu.
Checks returned, incorrect account numbers, or EFT's rejected for insufficient funds or checks, which cannot otherwise be cashed, do not constitute payment

IMPORTANT INFORMATION

As not to delay processing of your payment or request for changes, do not include correspondence with your payment.

Keep your Plan informed of address changes

In order to protect you and your family’s rights, you should keep UnitedHealthcare informed of any changes in your address and the addresses of your family members by sending the updated information to:

UnitedHealthcare COBRA / Direct Bill Operations
P.O. Box 221709
Louisville, KY 40252

or email to: or visit our secure website, and use the Request Edit function from the left-hand side.

Contact UnitedHealthcare at 1-866-747-0048 for:

• Premium and/or invoice questions
• Coverage effective date questions

Contact the customer service number on the back of your ID card for:

• Detailed Plan Questions
• Claims Questions

***Please cut and return the remittance coupon below and return it with your payment.***
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{Participant Name}Due Date: 03/01/2010
{ParticipantCity, ST and Zip}

Mail and Make Checks Payable to:
UnitedHealthcare
P.O. Box 713082
Cincinnati, OH45271-3082

Z-1220

UHC Benefit Services

Abattista sarah 00092.00 06/01/2009