ADDITIONAL ITEMS                                                   
                Additional Item Description/Incurred Date/Product/Sub Group-8 Digit/Payroll Location                 

INVOICE NUMBER:     230110581479                                           PAGE:               1 of 1            
BILL ACCOUNT NUMBER:2401631001                                             PAID CLAIMS MONTH:  January 2023      
BILL ACCOUNT NAME:  Utz Quality Foods                                      CLAIMS PAID THRU:   01/06/2023        
CLIENT NUMBER:      240163                                                 BILL CYCLE:         1 of 4            
CLIENT NAME:        Utz Quality Foods                                      PREPARED DATE:      01/10/2023        

                                        Adjustment Description                                            Adjustment Amount                              
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Stop Loss Estimate
  01/23
    PPO
      025620-01
         PLT4                                                                                                       ($379.77)
         PLT5                                                                                                    ($51,272.63)
         PLT4                                                                                                       ($117.00)
         PLT5                                                                                                       ($163.23)
      025620-01 Total                                                                                            ($51,932.63)
    PPO Total                                                                                                    ($51,932.63)
  01/23 Total                                                                                                    ($51,932.63)
Stop Loss Estimate Total                                                                                         ($51,932.63)
                                                                                                                                                            
Additional Items Total                                                                                           ($51,932.63)