HomeMy WebLinkAboutInv# 4374456 - NATIONAL VISION ADMINISTRATORS LLC - 08/17/2021NVA NATIONAL VISION ADMINISTRATORS, LLC (973) 574 - 2400
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PREMIUM INVOICE
CUSTOMER NO: 3117
INVOICE NO: 4374456
PAULA MORRELL CITY OF DANIA BEACH 100 W DANIA BEACH BLVD DANIA BEACH, FL 33004
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--- 8-17-2021 CHARGES, FEES AND ADJUSTMENTS For The Month Of : September
PVP - MONTHLY PREMIUM $1,936.40 = $1,936.40
PVP - PREMIUM ADJUSTMENT ($14.01) CR = ($14.01) CR
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Current Period Total: = $1,922.39
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--- PAYMENT DUE DATE: DUE UPON RECEIPT *** PAY THIS AMOUNT : $1,922.39 _________________
Please contact Collections @ 973-574-2549 if you have past due balances that you have not yet paid.
--- BALANCES: Total Current 31 - 60 Days 61 - 90 Days Over 90 Days
$1,922.39 $1,922.39 $0.00 $0.00 $0.00
Please remove the bottom portion of invoice and return with your payment. Please pay invoice in full. Any member additions and/or deletions
will appear on your next invoice. For questions regarding your invoice please call (973) 574 - 2400.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (return this portion with payment) National Vision Administrators Remittance Advice ( return this portion with payment)
INVOICE NO: 4374456 PAYMENT DUE DATE: DUE UPON RECEIPT
CUSTOMER NO: 3117 AMOUNT DUE: $1,922.39
INVOICE DATE: 8-17-2021 AMOUNT REMITTED: $ _________________
** Please Remit to : NATIONAL VISION ADMINISTRATORS, LLC P.O. Box 416421 Boston, MA 02241-6421
REFXX202109:3117 PREMIUM STATEMENT PAGE: 1
NATIONAL VISION ADMINISTRATORS Billing Month: SEPTEMBER,2021
1200 ROUTE 46 WEST No. of Months: 1
CLIFTON, NJ 07013
800-672-7723 Due Date: UPON RECEIPT
CITY OF DANIA BEACH
100 W DANIA BEACH BLVD
DANIA BEACH, FL 33004
MAIN: NVAI NATIONAL VISION ADMINISTRATORS, LLC.
FUNDING: RISK C NVAI RISK FUNDING LEVEL
GROUP: 3117 CITY OF DANIA BEACH
DIVISION: 31170000 CITY OF DANIA BEACH
CLASS: 3117000001 CITY OF DANIA BEACH
SUBID SUBSCRIBER NAME COV EFF DATE ADJ FROM ADJ TO CHARGE
----- --------------- --- --------- -------- ------ ------
XXX-XX-8432 ACOSTA, RAFAEL F 10/01/2019 12.36
XXX-XX-8998 ADAMS, LORI S 10/01/2020 5.15
XXX-XX-0750 ALI, RICKY A F 10/01/2019 12.36
XXX-XX-2208 ALPHONSE, LOU F 10/01/2020 12.36
XXX-XX-8024 ANSBRO, THOMAS F 10/01/2019 12.36
XXX-XX-1518 BALDIE, TOMMY R F 10/01/2019 12.36
XXX-XX-3121 BORDY, KATIA S 10/01/2019 5.15
XXX-XX-5607 BORGOS, LUIS F 01/01/2021 12.36
XXX-XX-3921 BOUTSIS, EVE S 03/02/2020 5.15
XXX-XX-6514 BROWN, ERIC F 10/01/2020 12.36
XXX-XX-7370 BROWN, LOUIS S 10/01/2019 5.15
XXX-XX-5345 BROWN, RODRICK F 10/01/2019 12.36
XXX-XX-9590 CANGIALOSI, JOSEPH S S 09/01/2020 5.15
XXX-XX-7291 CARRIE, ANNE-CHRISTINE S 01/01/2021 5.15
XXX-XX-6641 CASENEUVE, BENDRA F 10/01/2019 12.36
XXX-XX-4459 CHEN, MICHAEL K F 01/01/2021 12.36
XXX-XX-3854 CIGUENE, MAUDELINE F 10/01/2019 12.36
XXX-XX-6724 CLARKE, LATISHA F 06/01/2021 12.36
XXX-XX-9275 CLAYTON, ERIKA C F 10/01/2019 12.36
XXX-XX-1963 COLLINS, ROGER J S 02/01/2021 5.15
XXX-XX-9708 COOK, RONALD L F 10/01/2019 12.36
XXX-XX-4504 COSTA, NATHAN J F 10/01/2019 12.36
XXX-XX-2837 CRAWFORD, RUPERT F 10/01/2019 12.36
XXX-XX-3296 CROSS, JERRYLYN S 10/01/2019 5.15
XXX-XX-2274 DAMIS, WINDY F 10/01/2019 12.36
XXX-XX-8208 DAVILA, EDDA K S 06/01/2021 5.15
XXX-XX-3103 DAVIS, JOYCE L S 01/01/2021 5.15
XXX-XX-1304 DE JESUS, GABRIEL S 07/01/2020 5.15
XXX-XX-2516 DIPAOLO, FRANK L F 01/01/2020 12.36
XXX-XX-0586 DONNELLY, COLIN E F 10/01/2019 12.36
XXX-XX-3568 DOTSON, RICKEY S 09/01/2020 5.15
XXX-XX-2685 DRAKE, DONALD L F 10/01/2019 12.36
XXX-XX-4291 DRUMMOND, TAMARA S 10/01/2019 5.15
XXX-XX-4334 ERNST, ANNA BELLE B S 04/01/2021 5.15
XXX-XX-0462 FLORENCE, TARIF R S 07/01/2021 5.15
XXX-XX-4545 FLORES ORTIZ, YENI
END EMPLOYEE ADJ 08/01/21 08/31/21 -11.95
XXX-XX-8411 GAINES, TANEISHA S 10/01/2019 5.15
XXX-XX-4560 GAITHER, TIMOTHY F 10/01/2019 12.36
XXX-XX-1431 GARDNER, KALA F F 10/01/2019 12.36
XXX-XX-4466 GOODMAN, THOMAS F 10/01/2019 12.36
XXX-XX-4848 GRANT, MITCHELL V F 10/01/2019 12.36
XXX-XX-6620 GREENE, DARREN D F 10/01/2019 12.36
XXX-XX-3854 GUZMAN, YEIMY F 10/01/2019 12.36
XXX-XX-5928 HENLEY, ALICE S 10/01/2019 5.15
XXX-XX-6890 HORTON, TIMEKKA A S 08/01/2021 5.15
MISC CHARGE ADJ S 08/01/2021 08/01/21 08/31/21 5.15
XXX-XX-3431 HUCK, MICHAEL F 10/01/2019 12.36
XXX-XX-1869 HUGHES, ANASTACIA R F 10/01/2019 12.36
PREMIUM STATEMENT PAGE: 2
NATIONAL VISION ADMINISTRATORS Billing Month: SEPTEMBER,2021
1200 ROUTE 46 WEST No. of Months: 1
CLIFTON, NJ 07013
800-672-7723 Due Date: UPON RECEIPT
MAIN: NVAI NATIONAL VISION ADMINISTRATORS, LLC.
FUNDING: RISK C NVAI RISK FUNDING LEVEL
GROUP: 3117 CITY OF DANIA BEACH
DIVISION: 31170000 CITY OF DANIA BEACH
CLASS: 3117000001 CITY OF DANIA BEACH
SUBID SUBSCRIBER NAME COV EFF DATE ADJ FROM ADJ TO CHARGE
----- --------------- --- --------- -------- ------ ------
XXX-XX-8529 IBARGUEN, IBEL L S 10/01/2019 5.15
XXX-XX-9001 ICENHOUR, RACHEL F 10/01/2019 12.36
XXX-XX-5571 IFEDI, ANTHONY S 10/01/2019 5.15
XXX-XX-2519 ISMAIL, HAKEEM O F 10/01/2019 12.36
XXX-XX-6773 JACKSON, JOHNATHAN S 10/01/2020 5.15
XXX-XX-1109 JAMES, TAMARA F 10/01/2019 12.36
XXX-XX-9203 JAMES, TAMMIE D F 10/01/2019 12.36
XXX-XX-5360 JELASO, MEGAN F 10/01/2019 12.36
XXX-XX-1807 JOHNSON, ANTOINE S 10/01/2020 5.15
XXX-XX-5338 JOHNSON, BRANDON S 10/01/2019 5.15
XXX-XX-5239 JOLLY, CORY F 10/01/2019 12.36
XXX-XX-2660 JOSEPH, BENET F 10/01/2019 12.36
XXX-XX-4281 JOSEPH, PATRICK S 05/01/2021 5.15
XXX-XX-7277 KALLICHARAN, CARL S 10/01/2019 5.15
XXX-XX-7765 LAJOIE, CORINNE A S 01/02/2020 5.15
XXX-XX-8653 LORBER, RICHARD G S 08/01/2020 5.15
XXX-XX-9419 LOTTIER, CHRISTINE A F 10/01/2019 12.36
XXX-XX-0377 LOZANDIER, DANIEL S 10/01/2019 5.15
XXX-XX-1442 LUNKINS, ANGEL F 10/01/2019 12.36
XXX-XX-9156 MANZANO, DONALDO F 10/01/2019 12.36
XXX-XX-7494 MARTIN, RALPH F 10/01/2020 12.36
XXX-XX-5174 MARTINEZ, GABRIEL S 10/01/2019 5.15
XXX-XX-7771 MCHELLON, DONIAL F 10/01/2019 12.36
XXX-XX-9491 MCLAREN, KRISTEN M S 01/01/2021 5.15
XXX-XX-6765 MCNABB, KENNETH L S 09/01/2020 5.15
XXX-XX-5509 MCNEAL, GREGORY S 10/01/2019 5.15
XXX-XX-0954 MYKOO, SHANESA S 10/01/2019 5.15
XXX-XX-1276 NICASIO, MELISSA S 10/01/2019 5.15
XXX-XX-0506 NORENA, ELEANOR F 10/01/2019 12.36
XXX-XX-1915 ODMAN, LAUREN B F 10/01/2019 12.36
XXX-XX-8160 OSTROFSKY, WARREN F 10/01/2019 12.36
XXX-XX-8258 OZAYDIN, DINCER A S 08/01/2020 5.15
XXX-XX-4137 PECORARO, SHERRY F 10/01/2019 12.36
XXX-XX-7881 PEGUERO, ULYSSES S 11/01/2019 5.15
XXX-XX-8010 PEIRCE, LOGAN S 10/01/2020 5.15
XXX-XX-0362 PEREZ, FRANK F 10/01/2019 12.36
XXX-XX-6494 PERRY, LEONARD H S 10/01/2019 5.15
XXX-XX-0189 PETERSON, TERRY F 10/01/2019 12.36
XXX-XX-6933 POLLARD, ALBERLEAN F 10/01/2019 12.36
XXX-XX-6523 REYES, EDDIE F 05/01/2020 12.36
XXX-XX-2692 REYES, MICHAEL S 08/01/2021 5.15
MISC CHARGE ADJ S 08/01/2021 08/01/21 08/31/21 5.15
XXX-XX-2789 RIVIERE, JOSEPH A F 10/01/2019 12.36
XXX-XX-8493 RODRIGUEZ, FERNANDO S 10/01/2019 5.15
XXX-XX-5437 RODRIGUEZ, HAROLD F 10/01/2019 12.36
XXX-XX-7953 RODRIGUEZ, MICHAEL S F 10/01/2019 12.36
XXX-XX-7577 RODRIGUEZ, RICHARD F 10/01/2019 12.36
XXX-XX-5272 SABINO, DEBORAH F 10/01/2020 12.36
XXX-XX-3271 SALGADO, JOSE F F 10/01/2019 12.36
XXX-XX-9826 SALVINO, MARCO S 02/01/2021 5.15
XXX-XX-2792 SANTANA TORRES, JULIO M S 10/01/2019 5.15
XXX-XX-1093 SAUNDERS, JANICE L F 02/01/2021 12.36
XXX-XX-7812 SCHNEIDER, THOMAS F 10/01/2019 12.36
XXX-XX-9906 SEGAL, ADAM F 10/01/2019 12.36
XXX-XX-9685 SHELEY, CHERIE S 10/01/2019 5.15
XXX-XX-0114 SOMERS, HOWARD P F 10/01/2019 12.36
XXX-XX-7420 SPENCER, WILLIE F 10/01/2019 12.36
XXX-XX-0009 STEINER, MURRAY S 10/01/2019 5.15
XXX-XX-3000 STEVENS, TANIA A F 10/01/2019 12.36
XXX-XX-6414 TAYLOR, CORRY G F 10/01/2019 12.36
PREMIUM STATEMENT PAGE: 3
NATIONAL VISION ADMINISTRATORS Billing Month: SEPTEMBER,2021
1200 ROUTE 46 WEST No. of Months: 1
CLIFTON, NJ 07013
800-672-7723 Due Date: UPON RECEIPT
MAIN: NVAI NATIONAL VISION ADMINISTRATORS, LLC.
FUNDING: RISK C NVAI RISK FUNDING LEVEL
GROUP: 3117 CITY OF DANIA BEACH
DIVISION: 31170000 CITY OF DANIA BEACH
CLASS: 3117000001 CITY OF DANIA BEACH
SUBID SUBSCRIBER NAME COV EFF DATE ADJ FROM ADJ TO CHARGE
----- --------------- --- --------- -------- ------ ------
XXX-XX-2257 TERRAZAS, MONICA M F 10/01/2019 12.36
XXX-XX-5513 THOMAS, AHMAD F 10/01/2019 12.36
XXX-XX-8608 UROW, BARBARA F 10/01/2019 12.36
XXX-XX-3526 VASQUEZ, JONATHAN
END EMPLOYEE ADJ 08/01/21 08/31/21 -12.36
XXX-XX-3294 VASTA, MICHAEL J S 10/01/2019 5.15
XXX-XX-8587 WAGNAC, TRINA C S 08/01/2021 5.15
XXX-XX-3790 WALTON, ERIC J F 10/01/2019 12.36
XXX-XX-6299 WAREN, CASSANDRA S 04/01/2021 5.15
XXX-XX-2750 WASHINGTON JR, WILLIS B F 10/01/2019 12.36
XXX-XX-0534 WEEKES, KATHLEEN A F 10/01/2019 12.36
XXX-XX-8629 WEST, COKENYA D F 10/01/2019 12.36
XXX-XX-3730 WESTBERRY, ANSON J S 10/01/2020 5.15
XXX-XX-2864 WHITE, DEON T S 10/01/2019 5.15
XXX-XX-2419 WHITE, GEORGE S 10/01/2019 5.15
XXX-XX-5133 WILLIAMS, DARIUS F 10/01/2020 12.36
XXX-XX-5606 WRITER, CYRUS S 10/01/2019 5.15
XXX-XX-9082 ZAPATA, MARLON S 10/01/2019 5.15
CLASS SUMMARY
Total Cardholders: 121
Total Vision Premiums: 1120.64
Total Adjustment Charges: 10.30
Total Adjustment Credits: -24.31
Total Billing Fees: .00
Total Due: 1106.63
PREMIUM STATEMENT PAGE: 4
NATIONAL VISION ADMINISTRATORS Billing Month: SEPTEMBER,2021
1200 ROUTE 46 WEST No. of Months: 1
CLIFTON, NJ 07013
800-672-7723 Due Date: UPON RECEIPT
MAIN: NVAI NATIONAL VISION ADMINISTRATORS, LLC.
FUNDING: RISK C NVAI RISK FUNDING LEVEL
GROUP: 3117 CITY OF DANIA BEACH
DIVISION: 31170000 CITY OF DANIA BEACH
CLASS: 3117000002 CITY OF DANIA BEACH (RETIREE)
SUBID SUBSCRIBER NAME COV EFF DATE ADJ FROM ADJ TO CHARGE
----- --------------- --- --------- -------- ------ ------
XXX-XX-9211 ADAMS, LAURA S 06/01/2020 5.15
XXX-XX-8897 BAKER, ERIC J S 10/01/2019 5.15
XXX-XX-5627 BAKER, JAMES M S 01/01/2020 5.15
XXX-XX-3877 BERNARDO, MICHAEL A F 10/01/2019 12.36
XXX-XX-2128 BERTINO, JOHN F 10/01/2019 12.36
XXX-XX-2973 BERTUCCIO, JOSEPH F 10/01/20 19 12.36
XXX-XX-5444 BLOCKER, CHRISTY L S 10/01/2019 5.15
XXX-XX-7484 BLUST, JAMES F 10/01/2019 12.36
XXX-XX-8183 BOLTON, CHESTER S 10/01/2019 5.15
XXX-XX-5187 BRANDES, GLORIA F 10/01/2019 12.36
XXX-XX-0777 BRAVE, JOANN S 10/01/2019 5.15
XXX-XX-1087 BROWN, KENNETH S S 02/01/2021 5.15
XXX-XX-6209 BROWN, MICHAEL L F 10/01/2019 12.36
XXX-XX-5022 CARUSO, BRUCE F 10/01/2019 12.36
XXX-XX-4866 CASASANTA, DAVID S F 10/01/2019 12.36
XXX-XX-2695 CHANDLER, CHRISTOPHER F 05/01/2021 12.36
XXX-XX-6841 CHERIAN, DANIEL F 10/01/2019 12.36
XXX-XX-4777 COOK, DOROTHY S 10/01/2019 5.15
XXX-XX-7110 CRANDON, FRANK R F 10/01/2019 12.36
XXX-XX-3411 DENNY, NANCI S 10/01/2019 5.15
XXX-XX-6534 DUBISKY, WILLIAM F 10/01/2019 12.36
XXX-XX-2890 FELICETTY, MARK T F 10/01/2019 12.36
XXX-XX-9701 FONDO, GAIL F 10/01/2019 12.36
XXX-XX-7385 GARCIA, GONZALO F 10/01/2019 12.36
XXX-XX-2879 GARDNER, EULA M S 10/01/2019 5.15
XXX-XX-1450 GENNARO, JOSEPH S 10/01/2019 5.15
XXX-XX-3189 GIAQUINTO, RALPH F 10/01/2019 12.36
XXX-XX-0886 GILMOND, RUSSELL K S 09/01/2020 5.15
XXX-XX-9690 GRAMMER, THOMAS S 10/01/2019 5.15
XXX-XX-9709 GREEN, JACK S 10/01/2019 5.15
XXX-XX-1463 HANSEN, DONALD R F 10/01/2019 12.36
XXX-XX-5766 HESS, ROBERT F 10/01/2019 12.36
XXX-XX-2914 HOLDEN JR, LOYD F 10/01/2019 12.36
XXX-XX-2690 HUMPHREY, JAMES M F 10/01/2019 12.36
XXX-XX-4976 HUSOSKY, JOSEPH A F 10/01/2020 12.36
XXX-XX-3488 JOHNSON, ANTHONY S 03/01/2020 5.15
XXX-XX-9983 JOHNSON, CHARLENE F 10/01/2019 12.36
XXX-XX-0170 JOHNSON, STANLEY F 10/01/2019 12.36
XXX-XX-2814 JONES, KRISTEN L F 10/01/2019 12.36
XXX-XX-4330 KENON, FLOYD F 10/01/2019 12.36
XXX-XX-0872 KIMMICH, ROBERT E F 10/01/2019 12.36
XXX-XX-1121 KIRBY, DONNA H F 10/01/2019 12.36
XXX-XX-8227 KOCH, KENNETH S 10/01/2019 5.15
XXX-XX-5628 LAND, KENNETH F 10/01/2019 12.36
XXX-XX-4622 LEXA, JOHN F 10/01/2019 12.36
XXX-XX-2258 LIEM, BRUCE S 04/01/2021 5.15
XXX-XX-9956 LIPMAN, RHONA F 10/01/2019 12.36
XXX-XX-8286 MACE, EUGENE F 10/01/2019 12.36
XXX-XX-6020 MARIANI, MARK F 10/01/2019 12.36
XXX-XX-8890 MASON, LINDA I S 10/01/2019 5.15
XXX-XX-5095 MCDONALD, MARY L S 10/01/2019 5.15
XXX-XX-3532 MIKES, ROBERT A S 10/01/2019 5.15
XXX-XX-4881 MILLER, MILES S 09/01/2020 5.15
XXX-XX-6287 MOLINA, DEBBIE D S 05/01/2021 5.15
XXX-XX-6261 MORRIS, GLENN F 10/01/2019 12.36
XXX-XX-6656 MULFORD, JAMES S 09/01/2020 5.15
XXX-XX-3715 MULLIKIN, JAMES S 10/01/2019 5.15
XXX-XX-4034 MUSTELIER JR, ENRIQUE S 10/01/2020 5.15
XXX-XX-3956 NADEAU, LARRY F 10/01/2019 12.36
XXX-XX-9584 ORLANDO, DOMINIC F F 10/01/2019 12.36
PREMIUM STATEMENT PAGE: 5
NATIONAL VISION ADMINISTRATORS Billing Month: SEPTEMBER,2021
1200 ROUTE 46 WEST No. of Months: 1
CLIFTON, NJ 07013
800-672-7723 Due Date: UPON RECEIPT
MAIN: NVAI NATIONAL VISION ADMINISTRATORS, LLC.
FUNDING: RISK C NVAI RISK FUNDING LEVEL
GROUP: 3117 CITY OF DANIA BEACH
DIVISION: 31170000 CITY OF DANIA BEACH
CLASS: 3117000002 CITY OF DANIA BEACH (RETIREE)
SUBID SUBSCRIBER NAME COV EFF DATE ADJ FROM ADJ TO CHARGE
----- --------------- --- --------- -------- ------ ------
XXX-XX-9794 PATELLARO, LOU ANN S 10/01/2019 5.15
XXX-XX-1703 PATTERSON, DIANNA L S 10/01/2020 5.15
XXX-XX-5751 PELLECER, SERGIO S 10/01/2020 5.15
XXX-XX-4134 PHANEUF, GARY S 10/01/2019 5.15
XXX-XX-6107 PINK, NELSON F 10/01/2019 12.36
XXX-XX-1307 RIGO, RUDOLF F 10/01/2019 12.36
XXX-XX-9189 ROBERSON, CHARLENE F 10/01/2019 12.36
XXX-XX-2327 RODRIGUEZ, JOSE S 10/01/2019 5.15
XXX-XX-7303 ROSE, PERRY F 10/01/2019 12.36
XXX-XX-5234 ROSS, FRANK E F 10/01/2019 12.36
XXX-XX-9591 RUETH, RICHARD F 10/01/2019 12.36
XXX-XX-2952 SATTERFIELD, NICKI J F 10/01/2020 12.36
XXX-XX-7697 SAVAGE, JAMES R F 10/01/2019 12.36
XXX-XX-9677 SLADE, CURTIS S 10/01/2019 5.15
XXX-XX-0780 SMITH, MICHAEL W S 10/01/2019 5.15
XXX-XX-3594 SNELL, ARNOLD J F 07/01/2020 12.36
XXX-XX-1800 STUBBS, DANIEL F 10/01/2019 12.36
XXX-XX-9137 SULLIVAN, DARIN S 10/01/2019 5.15
XXX-XX-1836 TARMEY, EDWARD F 10/01/2019 12.36
XXX-XX-1188 TUBRIDY, THOMAS F 10/01/2019 12.36
XXX-XX-5007 WALTERS, LEROY A F 10/01/2019 12.36
XXX-XX-0401 WARWICK, PANSY S 10/01/2019 5.15
XXX-XX-5162 WENTWORTH, JEAN S 08/01/2020 5.15
XXX-XX-6392 WHITAKER, STEPHEN S 10/01/2019 5.15
XXX-XX-0730 WILLIAMS, LEO F 10/01/2019 12.36
XXX-XX-2226 ZIDAR, MATTHEW F 10/01/2019 12.36
CLASS SUMMARY
Total Cardholders: 86
Total Vision Premiums: 803.40
Total Adjustment Charges: .00
Total Adjustment Credits: .00
Total Billing Fees: .00
Total Due: 803.40
PREMIUM STATEMENT PAGE: 6
NATIONAL VISION ADMINISTRATORS Billing Month: SEPTEMBER,2021
1200 ROUTE 46 WEST No. of Months: 1
CLIFTON, NJ 07013
800-672-7723 Due Date: UPON RECEIPT
MAIN: NVAI NATIONAL VISION ADMINISTRATORS, LLC.
FUNDING: RISK C NVAI RISK FUNDING LEVEL
GROUP: 3117 CITY OF DANIA BEACH
DIVISION: 31170000 CITY OF DANIA BEACH
CLASS: 3117000099 CITY OF DANIA BEACH COBRA
SUBID SUBSCRIBER NAME COV EFF DATE ADJ FROM ADJ TO CHARGE
----- --------------- --- --------- -------- ------ ------
XXX-XX-1670 MORRELL, PAULA F 10/01/2019 12.36
CLASS SUMMARY
Total Cardholders: 1
Total Vision Premiums: 12.36
Total Adjustment Charges: .00
Total Adjustment Credits: .00
Total Billing Fees: .00
Total Due: 12.36
DIVISION SUMMARY
Total Cardholders: 208
Total Vision Premiums: 1936.40
Total Adjustment Charges: 10.30
Total Adjustment Credits: -24.31
Total Billing Fees: .00
Total Due: 1922.39
GROUP SUMMARY
Total Cardholders: 208
Total Vision Premiums: 1936.40
Total Adjustment Charges: 10.30
Total Adjustment Credits: -24.31
Total Billing Fees: .00
Total Due: 1922.39
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