EMPLOYER BENEFIT UNDERWRITERS, INC.

100 LaCosta Lane, Suite 120, Daytona Beach, FL  32114
Phone (386) 274-2600 * Fax (386) 274-4111 * Email: Claims@ebu-inc.com

 MONTHLY AGGREGATE REPORT  

Group Name:

Month Reporting:

Policy Eff Date:

Contract Basis:

Specific Limit:

Factor Types:

Single

Family

Composite

Dental Single

Dental Family

Aggregate Factors:

$

$

$

$

$

               

                                                                      Attachment Point                              Total Claims Paid

Month

# Single

# Family

Month

Year to Date

Month

Year to Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Specific Claims Detail:

Month

Name

Amt over specific

Amt Reimbursed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prepared by:

Date:

TPA Name:

TPA Address:

TPA Phone:

TPA Fax:

(ebumpr.aug2000-S8.4)