HomeMy WebLinkAboutInv# 2025-00000340 - Fidelity Security Life Insurance Company - 04/30/2025 (2)eveEyeMed 4000 LUXOTTICA PL MASON OH 45040-8114
Forwarding Service Requested
THE CITY OF DANIA BEACH LINDA GONZALEZ 100 W. DANIA BEACH BLVD. DANIA BEACH FL 33004
BILLING PERIOD: April, 2025
FULL MONTH
COVERAGE TIER
Benefit Level 1
Employee Only
Employee+ 1
Employee + Family
RETROACTIVE ADJUSTMENTS
Retro 02/2025
Retro 03/2025
17,817
202S032S806 Ji-IS ]JOO 38195
1145 [17,817) 4 of6
[OM-BS]
SUMMARY INVOICE FOR: The City of Dania Beach
GROUP ID: 5000543
SUBGROUP ID: 1001
INVOICE NUMBER: 166728834
COUNT
124
62
58
RATE
$4.39
$8.33
$12.24
FULL MONTH TOTAL
RETRO ADJUSTMENT TOTAL
CURRENT BILLING PERIOD TOTAL
TOTAL
$544.36
$516.46
$709.92
$1,770.74
$3.91
($12.72)
($8.81)
$1,761.93
PAYMENT IS DUE IN FULL UPON RECEIPT eve THE INVOICE CALCULATION IS BASED ON MEMBERSHIP AS OF 03/20/25 PLEASE DETACH AND RETURN
THE CITY OF DANIA BEACH LINDA GONZALEZ 100 W. DANIA BEACH BLVD. DANIA BEACH FL 33004
Remit To: FIDELITY SECURITY LIFE INSURANCE CO.PO BOX 632530 CINCINNATI OH 45263-2530
GROUP ID: 5000543
SUBGROUP ID: 1001
INVOICE NUMBER: 166728834
TOTAL INVOICE AMOUNT DUE: $1,761.93
7
FULL ROSTER
ROSTER LISTING FOR:The City of Dania Beach
BILLING PERIOD:April, 2025
INVOICE NUMBER:166728834 To view dependent members, please see the Enrollment Report at
eyemed.com/eyemanage
RETRO ADJUSTMENTS LIST
EM Subscriber ID Last Name First Name Plan Start Period Date End Period Date Retro Period Rate Division Code Location Code Company Code
30041810200 VLASIC ASHLEY Benefit Level 1 02/01/2025 02/28/2025 02/2025 $12.24
30041810200 VLASIC ASHLEY Benefit Level 1 02/01/2025 02/28/2025 02/2025 ($8.33)
Total Retro Adjustments for 02/2025 $3.91
26265777700 DIPAOLO FRANK Benefit Level 1 03/01/2025 03/31/2025 03/2025 ($12.24)
27475095000 QUINTERO JOHN Benefit Level 1 03/01/2025 03/31/2025 03/2025 ($4.39)
30041810200 VLASIC ASHLEY Benefit Level 1 03/01/2025 03/31/2025 03/2025 $12.24
30041810200 VLASIC ASHLEY Benefit Level 1 03/01/2025 03/31/2025 03/2025 ($8.33)
Total Retro Adjustments for 03/2025 ($12.72)
Total Retro Adjustments for the Month of April, 2025 ($8.81)
ROSTER REPORT