Insert Agency Letter Head

INSERT AGENCY LETTER HEAD

Unpaid Benefit Premium Billing Statement
Employee Name
EIN
Agency
PLAN CODE / PLAN DESCRIPTION / BENEFIT COVERAGE START DATE / BENEFIT COVERAGE END DATE / DUE DATE / AMOUNT DUE
Total Due:
/

If you fail to pay benefit premium before the due date, your benefit coverage will be cancelled retroactively to the last day of coverage for which the premiums were paid in full. If your benefit coverage has been cancelled for nonpayment, you responsible for any benefits claims on or after the start date of the unpaid premium.

If you receive a paycheck from the State of Arizona any amounts owed will be deducted from your pay.

Please write your Employee ID Number (EIN) on the front of your check or money order. Partial payments and over payments cannot be accepted and will be returned to sender. DO NOT MAIL CASH.

Remit Benefit Premium Payment to:

Arizona Department of Administration - HITF Accounting 100 N. 15th Avenue, Suite 202 Phoenix, AZ 85007

Unpaid Benefit Premium Billing Statement
Employee Name
EIN
Agency
PLAN CODE / PLAN DESCRIPTION / BENEFIT COVERAGE START DATE / BENEFIT COVERAGE END DATE / DUE DATE / AMOUNT DUE
Total Due:
/

If you fail to pay benefit premium before the due date, your benefit coverage will be cancelled retroactively to the last day of coverage for which the premiums were paid in full. If your benefit coverage has been cancelled for nonpayment, you responsible for any benefits claims on or after the start date of the unpaid premium.

If you receive a paycheck from the State of Arizona any amounts owed will be deducted from your pay.

Please write your Employee ID Number (EIN) on the front of your check or money order. Partial payments and over payments cannot be accepted and will be returned to sender. DO NOT MAIL CASH.

Remit Benefit Premium Payment to:

Arizona Department of Administration - HITF Accounting 100 N. 15th Avenue, Suite 202 Phoenix, AZ 85007

Last Updated: 8/15/2017