| Anytown USA | |||||||||
| Reimbursement Record | |||||||||
| $100,000 Deductible | |||||||||
| Policy period: 7/1/2003 - 6/30/2004 | |||||||||
| Contract: 12/24 | |||||||||
| Amount | Deductible | Amount over & | Date | Amount | Date | Outstanding | |||
| Name | Paid thru | of Claim | Level | Requested | Requested | Reimbursed | Reimbursed | Reimbursement | |
| Claimant A | Nov-03 | $100,419.00 | $100,000 | $419.00 | 29-Dec-03 | $419.00 | 15-Jan-04 | $0.00 | |
| Dec-03 | $1,201.82 | $1,201.82 | 19-Jan-04 | $1,201.82 | 6-Feb-04 | $0.00 | |||
| Jan-04 | $1,351.37 | $1,351.37 | 17-Feb-04 | $1,351.37 | 4-Mar-04 | $0.00 | |||
| Total | $102,972.19 | $2,972.19 | $2,972.19 | $0.00 | |||||
| Claimant C | Nov-03 | $107,581.68 | $100,000 | $7,581.68 | 31-Dec-03 | $7,581.68 | 15-Jan-04 | $0.00 | |
| Dec-03 | $3,308.01 | $3,308.01 | 19-Jan-04 | $3,308.01 | 6-Feb-04 | $0.00 | |||
| Jan-04 | $25,621.88 | $25,621.88 | 25-Feb-04 | $25,621.88 | 8-Mar-04 | $0.00 | |||
| Total | $136,511.57 | $36,511.57 | $36,511.57 | $0.00 | |||||
| Claimant D | Dec-03 | $103,614.37 | $100,000 | $3,614.37 | 30-Jan-04 | $3,614.37 | 13-Feb-04 | $0.00 | |
| Jan-04 | $27,122.00 | $27,122.00 | 25-Feb-04 | $27,122.00 | 15-Mar-04 | $0.00 | |||
| Total | $130,736.37 | $30,736.37 | $30,736.37 | $0.00 | |||||
| Total for All | $370,220.13 | $70,220.13 | $70,220.13 | $0.00 | |||||