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Inv# 165199960 - Fidelity Security Life Insurance Company - 05/02/2022 (2)
FULL MONTH LIST EM Subscriber ID Last Name First Name 26265734500 ACOSTA RAFAEL 26265766300 ADAMS LORI 26265741800 Adams Laura 26265731400 ALI RICKY 26265784900 ALPHONSE LOU 26918422000 ANAYA ALEXANDRA 26265753100 ANSBRO THOMAS 26265756800 BAKER ERIC 26265758800 BAKER JAMES 26265787900 BALDIE TOMMY 26265744800 BERNARDO MICHAEL 27551170300 Bertino Barbara 26265772700 BERTUCCIO JOSEPH 26265752100 BLOCKER CHRISTY 26265750000 Blust James 26265744200 BOLTON CHESTER 26265784500 BORDY KATIA 26265793500 Borgos Luis 26265734000 BOUTSIS EVE 26265761200 BRANDES GLORIA 26265740100 BRAVE JOANN 26265755200 BROWN MICHAEL 26265791500 Brown Kenneth INVOICE NUMBER:165199960 FULL ROSTER ROSTER LISTING FOR:The City of Dania Beach BILLING PERIOD:April, 2022 26265754300 BROWN LOUIS 26265783800 BROWN RODRICK 26265753200 BROWN ERIC 27498160300 BROWNE JOHNATHAN 26265792000 Cangialosi Joseph 26265735800 CARUSO BRUCE 26265739500 CASASANTA DAVID 26265786600 Chandler Christopher 26265749600 Chen Michael 26265792500 CHERIAN DANIEL 27431564600 Chong Johann 26265778100 CIGUENE MAUDELINE 26265757500 CLAYTON ERIKA 26265786300 Collins Roger 26265770200 Cook Dorothy 26265787600 COOK RONALD 26265771800 COSTA NATHAN 26265754100 CRANDON FRANK 26265788400 CRAWFORD RUPERT 26265743800 CROSS JERRYLYN 26265776000 DAMIS WINDY 27304666100 Dara Michael 26265788900 DAVILA EDDA 26265766900 Davis Joyce 26265737000 DE JESUS Gabriel 26265751400 DENNY NANCI 26265777700 DIPAOLO FRANK 26265736100 DONNELLY COLIN 26265763800 DOTSON RICKEY 26265748600 DRAKE DONALD 26265776900 DRUMMOND TAMARA 26265764600 DUBISKY WILLIAM 27498159900 EKLE ROBERT 26265782200 FLORENCE TARIF 26265765400 FONDO GAIL 26265790200 GAINES TANEISHA 26265779100 GAITHER TIMOTHY 26265759600 GARCIA GONZALO 26265789700 GARDNER KALA 26265764100 GARDNER EULA 26265732300 Gennaro Joseph 26265732500 Giaquinto Ralph 26265770400 GILMOND RUSSELL 26265741600 GOODMAN THOMAS 26265760000 Grammer Thomas 26265769700 GRANT MITCHELL 26265766500 Green Jack 26265779500 GREENE DARREN 26265733600 Hansen Donald 26265764900 HARRIS WILLIAM 26265740800 HENLEY ALICE 26265769300 Hess Robert 27523150200 HIRSCH STACY 26265747100 HOLDEN LlOYD 26265770900 HUCK MICHAEL 26265788700 HUGHES ANASTACIA 26265747600 HUMPHREY JAMES 26265752700 HUSOSKY JOSEPH 26265789100 ICENHOUR RACHEL 26265742400 IFEDI ANTHONY 26265787400 JACKSON JOHNATHAN 26265759300 JAMES TAMMIE 26265784600 JAMES TAMARA 26265775500 JELASO MEGAN 26265742000 JOHNSON CHARLENE 26265791600 JOHNSON ANTOINE 26265787100 JOHNSON STANLEY 26265759000 JOHNSON ANTHONY 26265774300 JOHNSON BRANDON 27371199000 JOHNSON JR KENNITH 26265791100 JOLLY CORY 26265738400 JONES KRISTEN 26265784100 JOSEPH BENET 26265782700 JOSEPH PATRICK 26265737900 KALLICHARAN CARL 26265751000 KENON FLOYD 26265747000 KIMMICH ROBERT 26265762000 KIRBY DONNA 26265738300 KOCH KENNETH 26265765000 LAJOIE CORINNE 26265752400 LAND KENNETH 26265793700 LARIOS IBARGUEN IBEL 26265752800 LEXA JOHN 26265744500 Liem Bruce 26265736600 Lorber Richard 26265739100 LOTTIER CHRISTINE 26265790900 LOZANDIER DANIEL 26265754500 MACE EUGENE 26265767100 MARIANI MARK 26265730200 Martin Ralph 26265775100 MARTINEZ GABRIEL 26265766100 MASON LINDA 26265748300 MCDONALD MARY 27344168300 MCDOWELL KEITH 27551170900 MCFARLANE DARRYL 26265747300 MCHELLON DONIAL 26265774800 McLaren Kristen 26265760800 McNabb Kenneth 26265780800 MCNEAL GREGORY 27551171500 MERCADO KARLA 26265751900 MIKES ROBERT 26265751700 Miller Miles 26265753400 Molina Debbie 26340914900 Morrell Paula 26265773300 MORRIS GLENN 26265753600 Mulford James 26265773500 MUSTELIER JR ENRIQUE 26265785200 MYKOO SHANESA 26265783200 NORENA ELEANOR 26265758300 ODMAN LAUREN 26265794800 ORLANDO DOMINIC 26265793100 OSTROFSKY WARREN 26265786100 Ozaydin Dincer 27146264200 Palm Grace 26265768900 PATELLARO LOU ANN 26265758100 PATTERSON DIANNA 26265774500 PECORARO SHERRY 26265773100 PEGUERO ULYSSES 26265776400 PEIRCE LOGAN 26265740600 PELLECER SERGIO 26265774100 PEREZ FRANK 26265772200 PERRY LEONARD 26265769600 PETERSON TERRY 26265749500 Pink Nelson 26265770000 POLLARD ALBERLEAN 27475095000 QUINTERO JOHN 26265791900 REYES EDDIE 26265770300 Reyes Michael 26265735300 Rigo Rudolf 26265763100 RIVIERE JOSEPH 26265745600 Roberson Charlene 26265745100 Rodriguez Jose 26265750100 RODRIGUEZ MICHAEL 26265778500 RODRIGUEZ HAROLD 26265773800 RODRIGUEZ RICHARD 26265737300 RODRIGUEZ FERNANDO 26265757000 ROSE PERRY 26265765700 ROSS FRANK 26265761500 RUETH RICHARD 26265756100 SABINO DEBORAH 26265782500 SALGADO JOSE 26265755700 Salvino Marco 27453488400 SANABRIA DAVID 27431566000 SANCHEZ CLAUDIA 26265792200 SANTANA TORRES JULIO 26265767400 SATTERFIELD NICKI 26265789400 SAUNDERS JANICE 26265745200 SAVAGE JAMES 26265771300 SCHNEIDER THOMAS 26265780600 SEGAL ADAM 26265747900 SHELEY CHERIE 26505006400 Singh Maxine 26265746000 SLADE CURTIS 26265753500 SMITH MICHAEL 26265762500 Snell Arnold 26265792800 SOMERS HOWARD 26265743300 SPENCER WILLIE 26265733300 STEINER MURRAY 26265781200 STEVENS TANIA 26265753700 STUBBS DANIEL 26265795200 Sullivan Darin 26265742900 TARMEY EDWARD 26265790400 TAYLOR CORRY 26265781900 TERRAZAS MONICA 26265748900 THOMAS AHMAD 26265750700 TUBRIDY THOMAS 26265733000 UROW BARBARA 26340925000 URTECHO JOSE 26265737500 VASTA MICHAEL 26265776600 WALTERS LEROY 26265779300 WALTON ERIC 26265769400 WAREN CASSANDRA 26265788200 WARWICK PANSY 26265785400 WASHINGTON JR WILLIS 26265794500 WEEKES KATHLEEN 26265746700 WENTWORTH JEAN 26265760300 WEST COKENYA 26265781600 WESTBERRY ANSON 26265771500 Whitaker Stephen 26265763500 WHITE GEORGE 26265746500 WHITE DEON 26265768600 WILLIAMS LEO 26265778800 Williams Darius 26265775300 WRITER CYRUS 26265785800 ZAPATA MARLON 26265750300 Zidar Matthew Billing Tier Plan Rate Division Code Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 To view dependent members, please see the Enrollment Report at ROSTER REPORT Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee + 1 Benefit Level 1 $8.33 Employee Only Benefit Level 1 $4.39 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Employee + Family Benefit Level 1 $12.24 Employee Only Benefit Level 1 $4.39 Employee Only Benefit Level 1 $4.39 Employee + 1 Benefit Level 1 $8.33 Location Total: $1,593.57 Full Month Total: $1,593.57 Location Code Company Code To view dependent members, please see the Enrollment Report at eyemed.com/eyemanage RETRO ADJUSTMENTS LIST EM Subscriber ID Last Name First Name 27498160300 BROWNE JOHNATHAN 26265794000 Carrie Anne-Christine 26265794200 GUZMAN YEIMY 27475095000 QUINTERO JOHN Total Retro Adjustments for 03/2022 Total Retro Adjustments for the Month of April, 2022 INVOICE NUMBER:165199960 FULL ROSTER ROSTER LISTING FOR:The City of Dania Beach BILLING PERIOD:April, 2022 Plan Start Period Date End Period Date Retro Period Rate Benefit Level 1 03/01/2022 03/31/2022 03/2022 $8.33 Benefit Level 1 03/01/2022 03/31/2022 03/2022 ($4.39) Benefit Level 1 03/01/2022 03/31/2022 03/2022 ($8.33) Benefit Level 1 03/01/2022 03/31/2022 03/2022 $4.39 Total Retro Adjustments for 03/2022 $0.00 Total Retro Adjustments for the Month of April, 2022 $0.00 To view dependent members, please see the Enrollment Report at ROSTER REPORT Division Code Location Code Company Code To view dependent members, please see the Enrollment Report at eyemed.com/eyemanage