HI 01001: Supplementary Medical Insurance
| To: | Railroad Retirement Board |
| Health Benefits | |
| 844 Rush Street | |
| Chicago, Illinois 60611 | |
| From: | SSA PSC NE MAT SE GL MAM WN DBP DIO |
| RE: | RR No. (RRB Annuity No.) |
| SSA CAN (SSN/BIC) | |
| Name |
SMI jurisdiction transfer processed (mo/da/yr). The correct premium due amount as of SOM (mo/yr) was ($$$¢¢) (overage, arrearage). SSA collected premiums through coverage month (mo/yr).