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Home My WebLink AboutInv# NY Life 0522 - LIFE INSURANCE COMPANY OF NORTH AMERICA - 05/18/2022oo!)t!o P6 =-2=oF'!<Irt-4'B F= ll! !l m3 HPf i i! iEF i+FgEHFBEgFEE 9$FEE$tiiilEEE gl $E dsp Ee EE! ; iui* = - Katui-t t; EH EgE 51 5 I 5 i 5 t flT sE 6E!i'=;:E =E 3;Egq"sl=+ei=i 3i +Eln1neE == ? c 1 E, 2 ^ gr F; 9f'E=idr i* t??EeEfi^Z1E=E *: ;i:-;.;f;''# Z = H ,, H6trnE-nd lll t *;fi I !, !, -:9 P99 P I9 !j !J r. r.9 p9 p 999!4grorqlr o (,l i! is t:r.oB B d d e B I6 e B I B B E:5 E B = E gE ?-- eas)S,q<< I \-./ \ h - Q) P o zt t- Iozjt |tt- C- Employee ID SSN First Name Middle Name Last Name Date of Birth Age as of Plan Year Start Age as of Calendar Start Age as of Bill Start 1860 133748432 RAFAEL ACOSTA 6/23/1979 42 42 42 1795 030468998 LORI ADAMS 1/16/1959 62 62 63 1809 104580750 RICKY A ALI 2/3/1976 45 45 46 1951 593592208 LOU ALPHONSE 11/2/1983 37 38 38 1987 591947186 ALEXANDRA ANAYA 9/28/1982 39 39 39 1958 590154460 ALEJANDRO AZCANO 7/29/1991 30 30 30 1784 594501518 TOMMY RICARDO BALDIE 3/27/1974 47 47 48 1869 593273121 KATIA BORDY 12/5/1971 49 50 50 1976 075605607 Luis Borgos 1/9/1974 47 47 48 1963 130563921 EVE BOUTSIS 8/25/1969 52 52 52 1919 263976514 ERIC BROWN 6/20/1966 55 55 55 549 264917370 LOUIS BROWN 1/14/1967 54 54 55 1643 593225345 RODRICK BROWN 4/30/1982 39 39 40 2018 592925293 JOHNATHAN BROWNE 7/31/1967 54 54 54 1325 595629590 Joseph S Cangialosi 4/10/1974 47 47 48 1975 262924459 Michael KENNETH Chen 4/11/1950 71 71 72 2014 216498465 Johann Chong 4/12/1977 44 44 45 1819 590653854 MAUDELINE CIGUENE 11/8/1981 39 40 40 1906 265699275 ERIKA C CLAYTON 6/22/1972 49 49 49 1978 594011963 Roger James Collins 12/10/1979 41 42 42 1950 594469708 RONALD LIDDELL COOK 9/17/1971 50 50 50 1749 560594504 NATHAN JAMES COSTA 2/3/1980 41 41 42 1923 594642837 RUPERT CRAWFORD 11/30/1975 45 46 46 1641 261153296 JERRYLYN CROSS 3/15/1954 67 67 68 1806 590322274 WINDY DAMIS 1/24/1985 36 36 37 1990 594908208 EDDA K DAVILA 8/14/1984 37 37 37 1977 307023103 Joyce Lynn Davis 7/16/1975 46 46 46 1966 145821304 Gabriel DE JESUS 10/6/1987 33 34 34 1425 590602516 FRANK L DIPAOLO 8/25/1980 41 41 41 1989 743407853 MARIA M DOMINGUEZ 10/11/1977 43 44 44 1446 137620586 COLIN E DONNELLY 12/1/1967 53 54 54 1894 267733568 RICKEY DOTSON 3/24/1974 47 47 48 1787 262632685 DONALD LEE DRAKE 5/11/1961 60 60 60 1878 590484291 TAMARA DRUMMOND 4/4/1986 35 35 36 2020 590101123 ROBERT EKLE 1/17/1966 55 55 56 1825 070785730 KISHA EUGENE 9/3/1987 34 34 34 1992 592580462 TARIF RASHAD FLORENCE 4/27/1983 38 38 39 1813 595118411 TANEISHA GAINES 4/28/1991 30 30 31 1935 264734142 ANA M GARCIA 10/24/1961 59 60 60 1670 595091431 KALA F GARDNER 12/8/1981 39 40 40 1961 152386428 LINDA GONZALEZ 7/24/1963 58 58 58 1899 224554466 THOMAS GOODMAN 6/7/1985 36 36 36 1202 427334848 MITCHELL V GRANT 11/7/1965 55 56 56 1907 589712458 DARIUS D GREENE 8/30/1997 24 24 24 1239 591286620 DARREN D GREENE 8/8/1977 44 44 44 1884 271568606 WILLIAM G HARRIS 2/8/1956 65 65 66 1760 212235928 ALICE HENLEY 11/3/1988 32 33 33 2023 592784479 STACY HIRSCH 9/19/1974 47 47 47 2026 591331676 ERNEST HOGGINS 6/3/1993 28 28 28 1700 498703431 MICHAEL HUCK 2/29/1972 49 49 50 1767 594761869 ANASTACIA RENEE HUGHES 2/6/1984 37 37 38 1820 595049001 RACHEL ICENHOUR 11/14/1990 30 31 31 1856 238455571 ANTHONY IFEDI 9/17/1984 37 37 37 2028 154577765 CLAUDIO IGLESIAS GUTIERREZ 1/4/1978 43 43 44 1910 594316773 JOHNATHAN JACKSON 4/11/1993 28 28 29 1949 266477473 ELLIS R JAMES 4/11/1958 63 63 64 1885 593281109 TAMARA JAMES 6/13/1984 37 37 37 1314 266499203 TAMMIE D JAMES 7/6/1963 58 58 58 1755 590085360 MEGAN JELASO 3/21/1986 35 35 36 1661 595341807 ANTOINE JOHNSON 12/13/1969 51 52 52 1948 589535338 BRANDON JOHNSON 6/4/1995 26 26 26 2013 266770217 KENNITH JOHNSON JR 2/14/1977 44 44 45 1890 595305239 CORY JOLLY 10/29/1984 36 37 37 1308 593272660 BENET JOSEPH 11/6/1958 62 63 63 1985 592904281 PATRICK JOSEPH 11/18/1989 31 32 32 1830 179807277 CARL KALLICHARAN 6/1/1957 64 64 64 1316 279627765 CORINNE A LAJOIE 8/4/1972 49 49 49 1931 767808529 IBEL E LARIOS IBARGUEN 3/12/1999 22 22 23 1732 589767387 Rachelle Lawson 6/11/1973 48 48 48 1924 140747042 LORI B LEWELLEN 11/16/1970 50 51 51 1967 143548653 Richard Glenn Lorber 2/14/1962 59 59 60 1430 191469419 CHRISTINE A LOTTIER 8/8/1959 62 62 62 1882 595210377 DANIEL LOZANDIER 2/23/1992 29 29 30 1973 103787494 Ralph Martin 2/24/1973 48 48 49 1814 589925174 GABRIEL MARTINEZ 12/8/1989 31 32 32 2021 772145490 JUAN MATOS 7/28/1988 33 33 33 1932 613079375 ERIN HEFLIN MCCLENDON 7/21/1977 44 44 44 2012 592985288 KEITH MCDOWELL 6/27/1989 32 32 32 2027 591309395 DARRYL MCFARLANE 7/22/1978 43 43 43 947 261897771 DONIAL MCHELLON 12/8/1966 54 55 55 1915 589789491 Kristen Marie McLaren 11/25/1988 32 33 33 1971 266856765 Kenneth L McNabb 8/8/1978 43 43 43 1937 592085509 GREGORY MCNEAL 1/10/1991 30 30 31 2022 605140173 KARLA MERCADO 10/15/1979 41 42 42 2025 772501841 FELICIA MILES 6/17/1983 38 38 38 1929 383706984 SHAWN PATRICK MURPHY 12/10/1957 63 64 64 1938 593650954 SHANESA MYKOO 1/28/1993 28 28 29 1789 593090506 ELEANOR NORENA 12/8/1980 40 41 41 1925 265951915 LAUREN BETH ODMAN 4/30/1979 42 42 43 1428 074508160 WARREN OSTROFSKY 7/15/1960 61 61 61 1970 593978258 Dincer Akin Ozaydin 2/11/1975 46 46 47 1797 589624137 SHERRY PECORARO 11/4/1978 42 43 43 1954 057827881 ULYSSES PEGUERO 4/2/1993 28 28 29 1847 590418010 LOGAN PEIRCE 3/22/1994 27 27 28 1750 589450362 FRANK PEREZ 10/4/1960 60 61 61 1453 005646494 LEONARD H PERRY 3/29/1957 64 64 65 1143 411190189 TERRY PETERSON 2/16/1960 61 61 62 1920 427496933 ALBERLEAN POLLARD 2/2/1984 37 37 38 2019 591111251 JOHN QUINTERO 3/9/1991 30 30 31 1964 594298057 SASHA RAMOS 4/15/1987 34 34 35 1770 595546523 EDDIE REYES 2/28/1970 51 51 52 1965 454412692 Michael Reyes 6/18/1974 47 47 47 1943 147568493 FERNANDO RODRIGUEZ 4/28/1960 61 61 62 1872 590675437 HAROLD RODRIGUEZ 9/13/1969 52 52 52 1680 262997953 MICHAEL S RODRIGUEZ 1/13/1978 43 43 44 1682 584357577 RICHARD RODRIGUEZ 2/3/1970 51 51 52 1959 267474096 FRANKLIN ROUSE 9/15/1959 62 62 62 1936 265395272 DEBORAH SABINO 9/8/1960 61 61 61 1168 592853271 JOSE F SALGADO 9/30/1964 57 57 57 1826 265119826 Marco Salvino 5/6/1953 68 68 68 2017 100765008 DAVID SANABRIA 8/15/1987 34 34 34 2015 589826745 CLAUDIA SANCHEZ 9/20/1975 46 46 46 1930 598302792 JULIO MANUEL SANTANA TORRES 5/18/1991 30 30 30 1321 595071093 JANICE L SAUNDERS 1/3/1960 61 61 62 1758 510627812 THOMAS SCHNEIDER 12/21/1957 63 64 64 1829 591879906 ADAM SEGAL 4/20/1971 50 50 51 1879 262379685 CHERIE SHELEY 8/22/1957 64 64 64 2008 592411842 KEVIN N SINGH 12/17/1976 44 45 45 2006 591984445 Maxine A Singh 10/17/1962 58 59 59 1746 072480114 HOWARD P.SOMERS 3/5/1956 65 65 66 1939 266890936 CANDIDO SOSA-CRUZ 9/17/1975 46 46 46 2031 593320598 MITZIE P SPEAR 9/26/1967 54 54 54 1853 254887420 WILLIE SPENCER 6/29/1952 69 69 69 1889 125500009 MURRAY STEINER 6/2/1958 63 63 63 1343 592103000 TANIA A STEVENS 7/25/1966 55 55 55 1439 595206414 CORRY G TAYLOR 2/24/1973 48 48 49 1822 592442257 MONICA M TERRAZAS 3/19/1971 50 50 51 946 262695513 AHMAD THOMAS 10/15/1974 46 47 47 2007 595256521 Chloe L Thomas 8/24/1992 29 29 29 1754 122468608 BARBARA UROW 7/7/1961 60 60 60 1676 154683294 MICHAEL J VASTA 11/25/1978 42 43 43 1984 147983731 MANUEL VILLALBA 1/21/1980 41 41 42 1443 591243790 ERIC J WALTON 1/5/1976 45 45 46 1981 392026299 CASSANDRA WAREN 4/15/1985 36 36 37 1205 593662750 WILLIS B WASHINGTON JR 10/7/1973 47 48 48 1753 087480534 KATHLEEN ANNE WEEKES 12/17/1948 72 73 73 1173 266798629 COKENYA D WEST 8/4/1977 44 44 44 1828 592213730 ANSON J.WESTBERRY 8/24/1989 32 32 32 1403 261672864 DEON T WHITE 11/8/1969 51 52 52 1790 267552419 GEORGE WHITE 12/10/1961 59 60 60 1972 590765133 Darius Williams 9/20/1988 33 33 33 1665 589935606 CYRUS WRITER 7/19/1984 37 37 37 1671 593919082 MARLON ZAPATA 6/16/1987 34 34 34 Address 1 Address 2 City State Zip/Postal Code Status Location Division 4051 SW 73 AVE Davie FL 33314 Active REC.ADM - Recreation/Administrative 6935 NW 16 Street Margate FL 33063 Active CTYA.ADM - City Attorney/Administrative 6863 NW 27 AVE Fort Lauderdale FL 33309 Active CD.CODE - Community Development/Code Compliance 225 NW 133RD STREET NORTH MIAMI FL 33168 Active PS.ST - Public Services/Streets 5940 N FARRAGUT DRIVE HOLLYWOOD FL 33021 Active PKG.OPS - Parking/Operations 7410 NW 10TH COURT PLANTATION FL 33313 Active REC.BCH - Recreation/Beach 1320 NW 132nd Terrace North Miami FL 33167 Active PS.PKL - Public Services/Parks and Landscaping 1001 NE 5 ST Hallandale Beach FL 33009 Active PS.ADM - Public Services/Administrative 7801 South Colony Circle #208 Tamarac FL 33321 Active FC.BM - Facilities Maintenance /Building Maintenan 612 SEVILLA AVENUE CORAL GABLES FL 33134 Active CTYA.ADM - City Attorney/Administrative 601 NW 34 TERRACE LAUDERHILL FL 33311 Active REC.ADM - Recreation/Administrative 1304 NW 2 STREET APT. B DANIA BEACH FL 33004 Active PS.ST - Public Services/Streets 5435 Mayo St Hollywood FL 33021 Active REC.ADM - Recreation/Administrative 8652 CLEAR LAKE LANE FT PEIRCE FL 34947 Active PS.ST - Public Services/Streets 11571 NW 2nd Street Plantation FL 33325 Active PS.PKL - Public Services/Parks and Landscaping 709 SW 13th St.Unit B Fort Lauderdale FL 33315 Active CRA.ADM - Community Redevelopment Agency/Administr 2951 SW 116 Avenue Apt 102 Miramar FL 33025 Active CD.BD - Community Development/Building 301 Seminole Palms Drive Greenacres FL 33463 Active FIN.ADM - Finance/Administrative 2209 Douglas Street Hollywood FL 33020 Active CLRK.ADM - City Clerk/Administrative 5584 Plunkett Street Hollywood FL 33021 Active PS.PKL - Public Services/Parks and Landscaping 1900 SABAL PALM DRIVE APT 304 DAVIE FL 33324 Active PS.WP - Public Services/Water Facilities 2980 NW 106th Avenue CORAL SPRINGS FL 33065 Active PS.WP - Public Services/Water Facilities 1130 SW 7TH AVENUE Deerfield Beach FL 33441 Active PS.UT - Public Services/Utilities 1925 NW 157 ST MIAMI GARDENS FL 33054 Active CD.CODE - Community Development/Code Compliance 1448 Holly Heights DR Apt 1 Fort Lauderdale FL 33304 Active CD.CODE - Community Development/Code Compliance 1990 NW 33RD COURT OAKLAND PARK FL 33309 Active CD.BD - Community Development/Building 500 NE 2ND STREET #227 DANIA BEACH FL 33004 Active COMM.ADM - Commission/Administrative 521 NW 11th Ave Boynton Beach FL 33435 Active PS.WP - Public Services/Water Facilities 5308 NW 83RD WAY Coral Springs FL 33067 Active FIN.ADM - Finance/Administrative 275R SW 8th St Rear House DANIA BEACH FL 33004 Active PS.ADM - Public Services/Administrative 5300 SW 30 Way Dania Beach FL 333126913 Active PS.ADM - Public Services/Administrative 1515 NW 82 ST Miami FL 33147 Active PKG.OPS - Parking/Operations 6413 PLUNKETT STREET HOLLYWOOD FL 33023 Active PS.UT - Public Services/Utilities 1490 Sheridan St.13 A Hollywood FL 33020 Active FIN.UT - Finance/Utilities 2418 SW 177 th av MIRAMAR FL 33029 Active PS.ST - Public Services/Streets 123 HIDDEN CT. RD 12-C HOLLYWOOD FL 33023 Active CRA.ADM - Community Redevelopment Agency/Administr 2641 NW 46th Avenue Lauderhill FL 33313 Active FIN.ADM - Finance/Administrative 724 NW 6 ST APT 1 Hallandale Beach FL 33009 Active FIN.ADM - Finance/Administrative 9381 SW 51 TERRACE MIAMI FL 33165 Active CM.ADM - City Manager/Administrative 609 SW 1ST Dania Beach FL 33004 Active REC.ADM - Recreation/Administrative 2811 MONTEVIDEO AVE COOPER CITY FL 33026 Active HR.ADM - Human Resources/Administrative 2631 Lee Hollywood FL 33020 Active PS.FLT - Public Services/Fleet Maintenance 4731 SW 66TH TERRACE DAVIE FL 33314 Active PS.PKL - Public Services/Parks and Landscaping 294 NW 13TH CT DANIA BEACH FL 33004 Active REC.ADM - Recreation/Administrative 294 NW 13TH COURT DANIA BEACH FL 33004 Active PS.UT - Public Services/Utilities 902 Natures Cove Rd Dania Beach FL 33004 Active CRA.ADM - Community Redevelopment Agency/Administr 11840 NW 11TH STREET PLANTATION FL 33323 Active REC.BCH - Recreation/Beach 19461 NE 19TH PLACE NORTH MIAMI FL 33179 Active CD.CODE - Community Development/Code Compliance 7780 NW 78th Ave Apt 113 Tamarac FL 33321 Active PS.UT - Public Services/Utilities 307 NE 8TH CT POMPANO BEACH FL 33060 Active REC.BCH - Recreation/Beach 3540 NW 50TH AVE L110 LAUDERDALE LAKES FL 33319 Active CD.BD - Community Development/Building 17324 NW 10 ST Pembroke Pines FL 33029 Active FIN.UT - Finance/Utilities 10741 N Saratoga Dr.Cooper City FL 33026 Active REC.ADM - Recreation/Administrative 1206 South 19th Avenue Hollywood FL 33020 Active FC.BM - Facilities Maintenance /Building Maintenan 2314 PERSHING ST APT 4 HOLLYWOOD FL 33020 Active PS.PKL - Public Services/Parks and Landscaping 255 NW 12TH AVENUE DANIA BEACH FL 33004 Active PS.PKL - Public Services/Parks and Landscaping 255 NW Tamara James Ave Dania Beach FL 33004 Active COMM.ADM - Commission/Administrative 255 NW Tamara James Ave.DANIA BEACH FL 33004 Active CD.BD - Community Development/Building 3509 LAKESIDE DRIVE DAVIE FL 33328 Active FIN.ADM - Finance/Administrative 2254 Charleston St.HOLLYWOOD FL 33020 Active PS.ADM - Public Services/Administrative 2307 HOPE ST HOLLYWOOD FL 33020 Active PS.PKL - Public Services/Parks and Landscaping 19401 NW 24th AVE MIAMI FL 33056 Active REC.ADM - Recreation/Administrative 225 NW 133 ST Miami FL 33168 Active FIN.UT - Finance/Utilities 4010 SW 59TH TERRACE WEST PARK FL 33023 Active PS.ST - Public Services/Streets 3500 Washington Street APT 310 Hollywood FL 33021 Active PS.ST - Public Services/Streets 6703 Rio Pinar North Lauderdale FL 33068 Active PS.PKL - Public Services/Parks and Landscaping 3714 PEBBLEBROOK MANOR COCONUT CREEK FL 33073 Active CD.ADM - Community Development/Administrative 4200 NW 3RD CT APT 201 PLANTATION FL 33317 Active CD.BD - Community Development/Building 4550 SW 23 TERRACE Dania Beach FL 33312 Active PS.ADM - Public Services/Administrative 4541 SW 27TH TERRACE DANIA BEACH FL 33312 Active COMM.ADM - Commission/Administrative 3305 N. 36TH AVENUE Hollywood FL 33021 Active CD.PL - Community Development/Planning and Zoning 8411 NW 17 COURT PEMBROKE PINES FL 33024 Active CM.ADM - City Manager/Administrative 495 NE 157 ST North Miami Beach FL 33162 Active CD.PL - Community Development/Planning and Zoning 6131 NW 55th Lane Tamarac FL 33319 Active IS.ADM - Information Systems/Administrative 4519 Tyler ST Hollywood FL 33021 Active PS.PKL - Public Services/Parks and Landscaping 1731 N 56TH AVE HOLLYWOOD FL 33021 Active PS.ST - Public Services/Streets 8311 NW 20TH STREET CORAL SPRINGS FL 33071 Active CLRK.ADM - City Clerk/Administrative 231 SW 8TH STREET DEERFIELD BEACH FL 33441 Active PS.ST - Public Services/Streets 8531 NW 41 Street Cooper City FL 33024 Active IS.ADM - Information Systems/Administrative 1535 SW 12 AVE APT 1 DANIA BEACH FL 33004 Active FIN.UT - Finance/Utilities 1430 SW 10TH ST.Fort Lauderdale FL 33312 Active REC.BCH - Recreation/Beach 3400 W HILLSBORO BLVD APT 201 Coconut Creek FL 33073 Active PS.UT - Public Services/Utilities 2430 NW 183RD STREET MIAMI GARDENS FL 33056 Active PS.ST - Public Services/Streets 832 Harbor Inn Drive Building 6 Coral Springs FL 33071 Active REC.ADM - Recreation/Administrative 2740 NW 11 Court Fort Lauderdale FL 33311 Active CD.CODE - Community Development/Code Compliance 5 DANBY PL BOYTON BEACH FL 33426 Active PS.WP - Public Services/Water Facilities 13831 NW 22ND COURT SUNRISE FL 33323 Active CD.BD - Community Development/Building 3905 JEFFERSON STREET HOLLYWOOD FL 33021 Active CD.ADM - Community Development/Administrative 2149 Anchor Court Dania Beach FL 33312 Active COMM.ADM - Commission/Administrative 1782 NW 97 AVENUE CORAL SPRINGS FL 33071 Active CD.CODE - Community Development/Code Compliance 3690 inverrary drive apt 2 G laudehill FL 33319 Active PS.ADM - Public Services/Administrative 901 SW 133 Avenue Davie FL 33325 Active FIN.UT - Finance/Utilities 501 NE 2nd Street APT. 1544 Fort Lauderale FL 33301 Active PS.PKL - Public Services/Parks and Landscaping 4166 S. pine island rd Davie FL 33328 Active FC.BM - Facilities Maintenance /Building Maintenan 2836 NW 110 TERRACE SUNRISE FL 33322 Active PS.ST - Public Services/Streets 1647 NE 185 STREET # 124 MIAMI FL 33179 Active PS.WP - Public Services/Water Facilities 4632 SW 37 AVENUE FORT LAUDERDALE FL 33312 Active CD.BD - Community Development/Building 3051 N.W. 30 Terrace OAKLAND PARK FL 33311 Active REC.ADM - Recreation/Administrative 1075 NE 127TH STREET APT 2 NORTH MIAMI FL 33161 Active PS.ADM - Public Services/Administrative 7161 WILSON STREET HOLLYWOOD FL 33024 Active FIN.ADM - Finance/Administrative 3445 NE 1ST COURT APT 202 POMPANO BEACH FL 33069 Active PS.UT - Public Services/Utilities 4561 NE 4TH AVENUE POMPANO BEACH FL 33064 Active HR.ADM - Human Resources/Administrative 5701 COLLINS AVENUE #1006 MIAMI BEACH FL 33140 Active PS.ADM - Public Services/Administrative 3730 SW 48 AVE #206 Pembroke Park FL 33023 Active PS.WP - Public Services/Water Facilities 2428 Oak Gardens Lane Hollywood FL 33020 Active PS.ST - Public Services/Streets 7261 POLK ST HOLLYWOOD FL 33024 Active PS.UT - Public Services/Utilities 5428 SW 23RD STREET WEST PARK FL 33023 Active PS.ST - Public Services/Streets 310 SE 3RD PLACE DANIA BEACH FL 33004 Active CD.ADM - Community Development/Administrative 271 NORTHEAST 142 STREET NORTH MIAMI FL 33161 Active PS.PKL - Public Services/Parks and Landscaping 713 NW 7 AVE Dania Beach FL 33004 Active COMM.ADM - Commission/Administrative 4304 NW 9TH AVE BOX 29 POMPANO BEACH FL 33064 Active PS.ST - Public Services/Streets 5350 King Arthur Avenue Davie FL 33331 Active HR.ADM - Human Resources/Administrative 64 MADRID LN DAVIE FL 33324 Active PS.WP - Public Services/Water Facilities 1791 Lyons Road Apt. 206 Coconut Creek FL FL 33063 Active CD.BD - Community Development/Building 3370 NW 21 AVENUE OAKLAND PARK FL 33309 Active CLRK.ADM - City Clerk/Administrative 2412 NE 4 Street E Pompano Beach FL 33062 Active FIN.ADM - Finance/Administrative 1305 NW 10 ST Dania Beach FL 33004 Active FIN.UT - Finance/Utilities 223 NE 107 STREET MIAMI FL 33161 Active PS.FLT - Public Services/Fleet Maintenance 4289 Diamond Drive Weston FL 33331 Active COMM.ADM - Commission/Administrative 9770 NW 24 Street CORAL SPRINGS FL 33065 Active PS.WP - Public Services/Water Facilities 230 SW 30TH CT.MIAMI FL 33135 Active CM.ADM - City Manager/Administrative 12048 NW 20 STREET PLANTATION FL 33323 Active HR.ADM - Human Resources/Administrative PO BOX 504 Fort Lauderdale FL 33302 Active FC.BM - Facilities Maintenance /Building Maintenan 324 SW 2nd Ave Dania Beach FL 330043949 Active PS.ST - Public Services/Streets 2620 East Aragon Boulevard #2 SUNRISE FL 33313 Active FIN.ADM - Finance/Administrative 2519 Oak Garden Lane Hollywood FL 33020 Active PS.ST - Public Services/Streets 11021 WEST BROWARD BOULEVARD PLANTATION FL 33324 Active IS.ADM - Information Systems/Administrative 246 NW 7 AVE DANIA BEACH FL 33004 Active PS.UT - Public Services/Utilities 4881 NW 94th Terrace Sunrise FL 33351 Active PS.ADM - Public Services/Administrative 4370 Fox Ridge DR WESTON FL 33331 Active PKG.OPS - Parking/Operations 2701 SW 5th St Delray Beach FL 334454420 Active REC.BCH - Recreation/Beach 3810 SW 58TH AVE WEST PARK FL 33023 Active PS.PKL - Public Services/Parks and Landscaping 3230 NW 66TH STREET FORT LAUDERDALE FL 33309 Active CD.CODE - Community Development/Code Compliance 8235 Cassia Terrace Tamarac FL 33321 Active REC.ADM - Recreation/Administrative 9571 NW 21 MANOR SUNRISE FL 33322 Active PS.UT - Public Services/Utilities 4400 HILLCREST DRIVE #515 HOLLYWOOD FL 33021 Active CRA.ADM - Community Redevelopment Agency/Administr 211 NW 12 AVENUE DANIA BEACH FL 33004 Active PS.PKL - Public Services/Parks and Landscaping 3041 NW 30th Avenue Oakland Park FL 33311 Active CD.CODE - Community Development/Code Compliance 200 NW 13th Court # 2 DANIA BEACH FL 33004 Active REC.ADM - Recreation/Administrative 4500 NW 15 STREET LAUDERHILL FL 33313 Active CD.CODE - Community Development/Code Compliance 641 SW 14TH COURT DEERFIELD FL 33441 Active PS.ST - Public Services/Streets 5092 S. UNIVERSITY DRIVE DAVIE FL 33328 Active REC.BCH - Recreation/Beach 1161 NW 47TH TERRACE MIAMI FL 33127 Active PS.UT - Public Services/Utilities Entity Benefit Class Carrier Coverage Type Plan Tier Benefit Eff. Date Benefit Term. Date City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 1/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 5/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 3/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 3/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Elected Officials)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 5/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Elected Officials)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 2/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 11/1/2021 City of Dania Beach Full Time (Elected Officials)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 6/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 2/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Elected Officials)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 3/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Elected Officials)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 3/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 3/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 1/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 12/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 5/1/2022 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 12/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life BasicLife Basic Life and AD&D 10/1/2021 Benefit Amount Volume Client Premium Pre-Tax Deduction Post-Tax Deduction No. of Deductions Contribution No. of Contributions $151,000.00 $151,000.00 $0.00 $0.00 $0.00 0 $15.10 24 $176,000.00 $176,000.00 $0.00 $0.00 $0.00 0 $17.60 24 $121,000.00 $121,000.00 $0.00 $0.00 $0.00 0 $12.10 24 $71,000.00 $71,000.00 $0.00 $0.00 $0.00 0 $7.10 24 $95,000.00 $95,000.00 $0.00 $0.00 $0.00 0 $9.50 24 $118,000.00 $118,000.00 $0.00 $0.00 $0.00 0 $11.80 24 $87,000.00 $87,000.00 $0.00 $0.00 $0.00 0 $8.70 24 $182,000.00 $182,000.00 $0.00 $0.00 $0.00 0 $18.20 24 $146,000.00 $146,000.00 $0.00 $0.00 $0.00 0 $14.60 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $121,000.00 $121,000.00 $0.00 $0.00 $0.00 0 $12.10 24 $81,000.00 $81,000.00 $0.00 $0.00 $0.00 0 $8.10 24 $101,000.00 $101,000.00 $0.00 $0.00 $0.00 0 $10.10 24 $93,000.00 $93,000.00 $0.00 $0.00 $0.00 0 $9.30 24 $100,000.00 $100,000.00 $0.00 $0.00 $0.00 0 $10.00 24 $73,000.00 $73,000.00 $0.00 $0.00 $0.00 0 $7.30 24 $161,000.00 $161,000.00 $0.00 $0.00 $0.00 0 $16.10 24 $96,000.00 $96,000.00 $0.00 $0.00 $0.00 0 $9.60 24 $77,000.00 $77,000.00 $0.00 $0.00 $0.00 0 $7.70 24 $115,000.00 $115,000.00 $0.00 $0.00 $0.00 0 $11.50 24 $179,000.00 $179,000.00 $0.00 $0.00 $0.00 0 $17.90 24 $115,000.00 $115,000.00 $0.00 $0.00 $0.00 0 $11.50 24 $98,000.00 $98,000.00 $0.00 $0.00 $0.00 0 $9.80 24 $115,000.00 $115,000.00 $0.00 $0.00 $0.00 0 $11.50 24 $121,000.00 $121,000.00 $0.00 $0.00 $0.00 0 $12.10 24 $73,000.00 $73,000.00 $0.00 $0.00 $0.00 0 $7.30 24 $107,000.00 $107,000.00 $0.00 $0.00 $0.00 0 $10.70 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $129,000.00 $129,000.00 $0.00 $0.00 $0.00 0 $12.90 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $99,000.00 $99,000.00 $0.00 $0.00 $0.00 0 $9.90 24 $124,000.00 $124,000.00 $0.00 $0.00 $0.00 0 $12.40 24 $87,000.00 $87,000.00 $0.00 $0.00 $0.00 0 $8.70 24 $89,000.00 $89,000.00 $0.00 $0.00 $0.00 0 $8.90 24 $129,000.00 $129,000.00 $0.00 $0.00 $0.00 0 $12.90 24 $120,000.00 $120,000.00 $0.00 $0.00 $0.00 0 $12.00 24 $128,000.00 $128,000.00 $0.00 $0.00 $0.00 0 $12.80 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $110,000.00 $110,000.00 $0.00 $0.00 $0.00 0 $11.00 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $175,000.00 $175,000.00 $0.00 $0.00 $0.00 0 $17.50 24 $128,000.00 $128,000.00 $0.00 $0.00 $0.00 0 $12.80 24 $70,000.00 $70,000.00 $0.00 $0.00 $0.00 0 $7.00 24 $170,000.00 $170,000.00 $0.00 $0.00 $0.00 0 $17.00 24 $177,000.00 $177,000.00 $0.00 $0.00 $0.00 0 $17.70 24 $119,000.00 $119,000.00 $0.00 $0.00 $0.00 0 $11.90 24 $111,000.00 $111,000.00 $0.00 $0.00 $0.00 0 $11.10 24 $95,000.00 $95,000.00 $0.00 $0.00 $0.00 0 $9.50 24 $152,000.00 $152,000.00 $0.00 $0.00 $0.00 0 $15.20 24 $103,000.00 $103,000.00 $0.00 $0.00 $0.00 0 $10.30 24 $96,000.00 $96,000.00 $0.00 $0.00 $0.00 0 $9.60 24 $158,000.00 $158,000.00 $0.00 $0.00 $0.00 0 $15.80 24 $106,000.00 $106,000.00 $0.00 $0.00 $0.00 0 $10.60 24 $76,000.00 $76,000.00 $0.00 $0.00 $0.00 0 $7.60 24 $82,000.00 $82,000.00 $0.00 $0.00 $0.00 0 $8.20 24 $78,000.00 $78,000.00 $0.00 $0.00 $0.00 0 $7.80 24 $147,000.00 $147,000.00 $0.00 $0.00 $0.00 0 $14.70 24 $121,000.00 $121,000.00 $0.00 $0.00 $0.00 0 $12.10 24 $168,000.00 $168,000.00 $0.00 $0.00 $0.00 0 $16.80 24 $71,000.00 $71,000.00 $0.00 $0.00 $0.00 0 $7.10 24 $111,000.00 $111,000.00 $0.00 $0.00 $0.00 0 $11.10 24 $104,000.00 $104,000.00 $0.00 $0.00 $0.00 0 $10.40 24 $89,000.00 $89,000.00 $0.00 $0.00 $0.00 0 $8.90 24 $103,000.00 $103,000.00 $0.00 $0.00 $0.00 0 $10.30 24 $183,000.00 $183,000.00 $0.00 $0.00 $0.00 0 $18.30 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $84,000.00 $84,000.00 $0.00 $0.00 $0.00 0 $8.40 24 $90,000.00 $90,000.00 $0.00 $0.00 $0.00 0 $9.00 24 $73,000.00 $73,000.00 $0.00 $0.00 $0.00 0 $7.30 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $134,000.00 $134,000.00 $0.00 $0.00 $0.00 0 $13.40 24 $119,000.00 $119,000.00 $0.00 $0.00 $0.00 0 $11.90 24 $129,000.00 $129,000.00 $0.00 $0.00 $0.00 0 $12.90 24 $105,000.00 $105,000.00 $0.00 $0.00 $0.00 0 $10.50 24 $71,000.00 $71,000.00 $0.00 $0.00 $0.00 0 $7.10 24 $136,000.00 $136,000.00 $0.00 $0.00 $0.00 0 $13.60 24 $76,000.00 $76,000.00 $0.00 $0.00 $0.00 0 $7.60 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $133,000.00 $133,000.00 $0.00 $0.00 $0.00 0 $13.30 24 $119,000.00 $119,000.00 $0.00 $0.00 $0.00 0 $11.90 24 $99,000.00 $99,000.00 $0.00 $0.00 $0.00 0 $9.90 24 $95,000.00 $95,000.00 $0.00 $0.00 $0.00 0 $9.50 24 $143,000.00 $143,000.00 $0.00 $0.00 $0.00 0 $14.30 24 $85,000.00 $85,000.00 $0.00 $0.00 $0.00 0 $8.50 24 $124,000.00 $124,000.00 $0.00 $0.00 $0.00 0 $12.40 24 $147,000.00 $147,000.00 $0.00 $0.00 $0.00 0 $14.70 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $73,000.00 $73,000.00 $0.00 $0.00 $0.00 0 $7.30 24 $137,000.00 $137,000.00 $0.00 $0.00 $0.00 0 $13.70 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $110,000.00 $110,000.00 $0.00 $0.00 $0.00 0 $11.00 24 $76,000.00 $76,000.00 $0.00 $0.00 $0.00 0 $7.60 24 $98,000.00 $98,000.00 $0.00 $0.00 $0.00 0 $9.80 24 $94,000.00 $94,000.00 $0.00 $0.00 $0.00 0 $9.40 24 $116,000.00 $116,000.00 $0.00 $0.00 $0.00 0 $11.60 24 $140,000.00 $140,000.00 $0.00 $0.00 $0.00 0 $14.00 24 $132,000.00 $132,000.00 $0.00 $0.00 $0.00 0 $13.20 24 $156,000.00 $156,000.00 $0.00 $0.00 $0.00 0 $15.60 24 $135,000.00 $135,000.00 $0.00 $0.00 $0.00 0 $13.50 24 $99,000.00 $99,000.00 $0.00 $0.00 $0.00 0 $9.90 24 $152,000.00 $152,000.00 $0.00 $0.00 $0.00 0 $15.20 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $114,000.00 $114,000.00 $0.00 $0.00 $0.00 0 $11.40 24 $95,000.00 $95,000.00 $0.00 $0.00 $0.00 0 $9.50 24 $138,000.00 $138,000.00 $0.00 $0.00 $0.00 0 $13.80 24 $92,000.00 $92,000.00 $0.00 $0.00 $0.00 0 $9.20 24 $132,000.00 $132,000.00 $0.00 $0.00 $0.00 0 $13.20 24 $133,000.00 $133,000.00 $0.00 $0.00 $0.00 0 $13.30 24 $73,000.00 $73,000.00 $0.00 $0.00 $0.00 0 $7.30 24 $71,000.00 $71,000.00 $0.00 $0.00 $0.00 0 $7.10 24 $141,000.00 $141,000.00 $0.00 $0.00 $0.00 0 $14.10 24 $108,000.00 $108,000.00 $0.00 $0.00 $0.00 0 $10.80 24 $115,000.00 $115,000.00 $0.00 $0.00 $0.00 0 $11.50 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $87,000.00 $87,000.00 $0.00 $0.00 $0.00 0 $8.70 24 $120,000.00 $120,000.00 $0.00 $0.00 $0.00 0 $12.00 24 $141,000.00 $141,000.00 $0.00 $0.00 $0.00 0 $14.10 24 $116,000.00 $116,000.00 $0.00 $0.00 $0.00 0 $11.60 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $141,000.00 $141,000.00 $0.00 $0.00 $0.00 0 $14.10 24 $94,000.00 $94,000.00 $0.00 $0.00 $0.00 0 $9.40 24 $128,000.00 $128,000.00 $0.00 $0.00 $0.00 0 $12.80 24 $179,000.00 $179,000.00 $0.00 $0.00 $0.00 0 $17.90 24 $189,000.00 $189,000.00 $0.00 $0.00 $0.00 0 $18.90 24 $159,000.00 $159,000.00 $0.00 $0.00 $0.00 0 $15.90 24 $151,000.00 $151,000.00 $0.00 $0.00 $0.00 0 $15.10 24 $86,000.00 $86,000.00 $0.00 $0.00 $0.00 0 $8.60 24 $174,000.00 $174,000.00 $0.00 $0.00 $0.00 0 $17.40 24 $120,000.00 $120,000.00 $0.00 $0.00 $0.00 0 $12.00 24 $71,000.00 $71,000.00 $0.00 $0.00 $0.00 0 $7.10 24 $191,000.00 $191,000.00 $0.00 $0.00 $0.00 0 $19.10 24 $200,000.00 $200,000.00 $0.00 $0.00 $0.00 0 $20.00 24 $143,000.00 $143,000.00 $0.00 $0.00 $0.00 0 $14.30 24 $90,000.00 $90,000.00 $0.00 $0.00 $0.00 0 $9.00 24 $81,000.00 $81,000.00 $0.00 $0.00 $0.00 0 $8.10 24 $107,000.00 $107,000.00 $0.00 $0.00 $0.00 0 $10.70 24 $81,000.00 $81,000.00 $0.00 $0.00 $0.00 0 $8.10 24 $121,000.00 $121,000.00 $0.00 $0.00 $0.00 0 $12.10 24 $97,000.00 $97,000.00 $0.00 $0.00 $0.00 0 $9.70 24 $120,000.00 $120,000.00 $0.00 $0.00 $0.00 0 $12.00 24 $110,000.00 $110,000.00 $0.00 $0.00 $0.00 0 $11.00 24 Monthly Carrier Premium Carrier Adjustment Adjusted Carrier Premium Client Adjustment Admin Fee Admin Fee Adjustment Total Fee Individual Stop Loss $30.20 $0.00 $30.20 $0.00 $0.00 $0.00 $35.20 $0.00 $35.20 $0.00 $0.00 $0.00 $24.20 $0.00 $24.20 $0.00 $0.00 $0.00 $14.20 $0.00 $14.20 $0.00 $0.00 $0.00 $19.00 $0.00 $19.00 $0.00 $0.00 $0.00 $23.60 $0.00 $23.60 $0.00 $0.00 $0.00 $17.40 $0.00 $17.40 $0.00 $0.00 $0.00 $36.40 $0.00 $36.40 $0.00 $0.00 $0.00 $29.20 $0.00 $29.20 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $24.20 $0.00 $24.20 $0.00 $0.00 $0.00 $16.20 $0.00 $16.20 $0.00 $0.00 $0.00 $20.20 $0.00 $20.20 $0.00 $0.00 $0.00 $18.60 $0.00 $18.60 $0.00 $0.00 $0.00 $20.00 $0.00 $20.00 $0.00 $0.00 $0.00 $14.60 $0.00 $14.60 $0.00 $0.00 $0.00 $32.20 $0.00 $32.20 $0.00 $0.00 $0.00 $19.20 $0.00 $19.20 $0.00 $0.00 $0.00 $15.40 $0.00 $15.40 $0.00 $0.00 $0.00 $23.00 $0.00 $23.00 $0.00 $0.00 $0.00 $35.80 $0.00 $35.80 $0.00 $0.00 $0.00 $23.00 $0.00 $23.00 $0.00 $0.00 $0.00 $19.60 $0.00 $19.60 $0.00 $0.00 $0.00 $23.00 $0.00 $23.00 $0.00 $0.00 $0.00 $24.20 $0.00 $24.20 $0.00 $0.00 $0.00 $14.60 $0.00 $14.60 $0.00 $0.00 $0.00 $21.40 $0.00 $21.40 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $25.80 $0.00 $25.80 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $19.80 $0.00 $19.80 $0.00 $0.00 $0.00 $24.80 $0.00 $24.80 $0.00 $0.00 $0.00 $17.40 $0.00 $17.40 $0.00 $0.00 $0.00 $17.80 $0.00 $17.80 $0.00 $0.00 $0.00 $25.80 $0.00 $25.80 $0.00 $0.00 $0.00 $24.00 $0.00 $24.00 $0.00 $0.00 $0.00 $25.60 $0.00 $25.60 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $22.00 $0.00 $22.00 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $35.00 $0.00 $35.00 $0.00 $0.00 $0.00 $25.60 $0.00 $25.60 $0.00 $0.00 $0.00 $14.00 $0.00 $14.00 $0.00 $0.00 $0.00 $34.00 $0.00 $34.00 $0.00 $0.00 $0.00 $35.40 $0.00 $35.40 $0.00 $0.00 $0.00 $23.80 $0.00 $23.80 $0.00 $0.00 $0.00 $22.20 $0.00 $22.20 $0.00 $0.00 $0.00 $19.00 $0.00 $19.00 $0.00 $0.00 $0.00 $30.40 $0.00 $30.40 $0.00 $0.00 $0.00 $20.60 $0.00 $20.60 $0.00 $0.00 $0.00 $19.20 $0.00 $19.20 $0.00 $0.00 $0.00 $31.60 $0.00 $31.60 $0.00 $0.00 $0.00 $21.20 $0.00 $21.20 $0.00 $0.00 $0.00 $15.20 $0.00 $15.20 $0.00 $0.00 $0.00 $16.40 $0.00 $16.40 $0.00 $0.00 $0.00 $15.60 $0.00 $15.60 $0.00 $0.00 $0.00 $29.40 $0.00 $29.40 $0.00 $0.00 $0.00 $24.20 $0.00 $24.20 $0.00 $0.00 $0.00 $33.60 $0.00 $33.60 $0.00 $0.00 $0.00 $14.20 $0.00 $14.20 $0.00 $0.00 $0.00 $22.20 $0.00 $22.20 $0.00 $0.00 $0.00 $20.80 $0.00 $20.80 $0.00 $0.00 $0.00 $17.80 $0.00 $17.80 $0.00 $0.00 $0.00 $20.60 $0.00 $20.60 $0.00 $0.00 $0.00 $36.60 $0.00 $36.60 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $16.80 $0.00 $16.80 $0.00 $0.00 $0.00 $18.00 $0.00 $18.00 $0.00 $0.00 $0.00 $14.60 $0.00 $14.60 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $26.80 $0.00 $26.80 $0.00 $0.00 $0.00 $23.80 $0.00 $23.80 $0.00 $0.00 $0.00 $25.80 $0.00 $25.80 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $14.20 $0.00 $14.20 $0.00 $0.00 $0.00 $27.20 $0.00 $27.20 $0.00 $0.00 $0.00 $15.20 $0.00 $15.20 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $26.60 $0.00 $26.60 $0.00 $0.00 $0.00 $23.80 $0.00 $23.80 $0.00 $0.00 $0.00 $19.80 $0.00 $19.80 $0.00 $0.00 $0.00 $19.00 $0.00 $19.00 $0.00 $0.00 $0.00 $28.60 $0.00 $28.60 $0.00 $0.00 $0.00 $17.00 $0.00 $17.00 $0.00 $0.00 $0.00 $24.80 $0.00 $24.80 $0.00 $0.00 $0.00 $29.40 $0.00 $29.40 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $14.60 $0.00 $14.60 $0.00 $0.00 $0.00 $27.40 $0.00 $27.40 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $22.00 $0.00 $22.00 $0.00 $0.00 $0.00 $15.20 $0.00 $15.20 $0.00 $0.00 $0.00 $19.60 $0.00 $19.60 $0.00 $0.00 $0.00 $18.80 $0.00 $18.80 $0.00 $0.00 $0.00 $23.20 $0.00 $23.20 $0.00 $0.00 $0.00 $28.00 $0.00 $28.00 $0.00 $0.00 $0.00 $26.40 $0.00 $26.40 $0.00 $0.00 $0.00 $31.20 $0.00 $31.20 $0.00 $0.00 $0.00 $27.00 $0.00 $27.00 $0.00 $0.00 $0.00 $19.80 $0.00 $19.80 $0.00 $0.00 $0.00 $30.40 $0.00 $30.40 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $22.80 $0.00 $22.80 $0.00 $0.00 $0.00 $19.00 $0.00 $19.00 $0.00 $0.00 $0.00 $27.60 $0.00 $27.60 $0.00 $0.00 $0.00 $18.40 $0.00 $18.40 $0.00 $0.00 $0.00 $26.40 $0.00 $26.40 $0.00 $0.00 $0.00 $26.60 $0.00 $26.60 $0.00 $0.00 $0.00 $14.60 $0.00 $14.60 $0.00 $0.00 $0.00 $14.20 $0.00 $14.20 $0.00 $0.00 $0.00 $28.20 $0.00 $28.20 $0.00 $0.00 $0.00 $21.60 $0.00 $21.60 $0.00 $0.00 $0.00 $23.00 $0.00 $23.00 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $17.40 $0.00 $17.40 $0.00 $0.00 $0.00 $24.00 $0.00 $24.00 $0.00 $0.00 $0.00 $28.20 $0.00 $28.20 $0.00 $0.00 $0.00 $23.20 $0.00 $23.20 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $28.20 $0.00 $28.20 $0.00 $0.00 $0.00 $18.80 $0.00 $18.80 $0.00 $0.00 $0.00 $25.60 $0.00 $25.60 $0.00 $0.00 $0.00 $35.80 $0.00 $35.80 $0.00 $0.00 $0.00 $37.80 $0.00 $37.80 $0.00 $0.00 $0.00 $31.80 $0.00 $31.80 $0.00 $0.00 $0.00 $30.20 $0.00 $30.20 $0.00 $0.00 $0.00 $17.20 $0.00 $17.20 $0.00 $0.00 $0.00 $34.80 $0.00 $34.80 $0.00 $0.00 $0.00 $24.00 $0.00 $24.00 $0.00 $0.00 $0.00 $14.20 $0.00 $14.20 $0.00 $0.00 $0.00 $38.20 $0.00 $38.20 $0.00 $0.00 $0.00 $40.00 $0.00 $40.00 $0.00 $0.00 $0.00 $28.60 $0.00 $28.60 $0.00 $0.00 $0.00 $18.00 $0.00 $18.00 $0.00 $0.00 $0.00 $16.20 $0.00 $16.20 $0.00 $0.00 $0.00 $21.40 $0.00 $21.40 $0.00 $0.00 $0.00 $16.20 $0.00 $16.20 $0.00 $0.00 $0.00 $24.20 $0.00 $24.20 $0.00 $0.00 $0.00 $19.40 $0.00 $19.40 $0.00 $0.00 $0.00 $24.00 $0.00 $24.00 $0.00 $0.00 $0.00 $22.00 $0.00 $22.00 $0.00 $0.00 $0.00 Individual Stop Loss AdjustmentAggregate Stop Loss Aggregate Stop Loss AdjustmentBill Date Generation Date Client ID Payment Tracker Amount Owed $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE 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Laurence Leeds 12/2/1952 68 69 69 269507993 Susan Lewis 1/6/1950 71 71 72 522 263774622 JOHN LEXA 12/16/1964 56 57 57 261272258 Bruce Liem 8/24/1961 60 60 60 021269956 Rhona Lipman 12/12/1935 85 86 86 909 264988286 EUGENE MACE 7/18/1953 68 68 68 366 032486020 MARK MARIANI 10/14/1956 64 65 65 1216 298488890 LINDA I MASON 3/21/1954 67 67 68 1259 262555095 MARY L MCDONALD 8/22/1960 61 61 61 780 263643532 ROBERT A MIKES 5/25/1942 79 79 79 263514881 Miles Miller 9/3/1967 54 54 54 163 578646261 GLENN MORRIS 11/15/1951 69 70 70 264236656 James Mulford 2/29/1956 65 65 66 672 582194034 ENRIQUE MUSTELIER JR 4/4/1959 62 62 63 988 049503956 LARRY NADEAU 8/16/1955 66 66 66 589775960 Miriam Nasser 4/30/1947 74 74 75 1391 092449584 DOMINIC F ORLANDO 7/3/1953 68 68 68 111385540 Francisco Osorio 3/8/1947 74 74 75 266984916 JERI A PAPPAS 10/28/1952 68 69 69 359 351469794 LOU ANN PATELLARO 7/12/1958 63 63 63 267906493 Lawrence Patrick 4/16/1951 70 70 71 141485281 Merle Patron 3/12/1949 72 72 73 713 205485751 SERGIO PELLECER 4/27/1965 56 56 57 262826107 Nelson Pink 5/29/1947 74 74 74 134201307 Rudolf Rigo 6/30/1928 93 93 93 267512789 JOSEPH A RIVIERE 1/16/1960 61 61 62 113364400 Robert Rizzo 6/26/1948 73 73 73 261569189 Charlene Roberson 9/12/1938 83 83 83 123456789 Marietta Rochelle-Warren 1/18/1956 65 65 66 261512327 Jose Rodriguez 4/29/1959 62 62 63 984 152441592 KERRY ROMAN 9/5/1951 70 70 70 134 265687303 PERRY ROSE 12/25/1942 78 79 79 1410 288525234 FRANK E ROSS 4/24/1953 68 68 69 102 266889591 RICHARD RUETH 10/13/1953 67 68 68 1323 326702952 NICKI J SATTERFIELD 9/17/1964 57 57 57 1082 261567697 JAMES R SAVAGE 8/18/1941 80 80 80 344208510 Norma Jean Signore 6/13/1928 93 93 93 264351002 Timothy Sklark 9/9/1957 64 64 64 1028 261599677 CURTIS SLADE 8/17/1962 59 59 59 267273091 Kathleen Smith 7/16/1944 77 77 77 378 264190780 MICHAEL W SMITH 3/8/1955 66 66 67 427665923 Rufus Sparks 2/5/1934 87 87 88 575 422701330 JOSEPH SPONGROSS 3/25/1951 70 70 71 861 264371800 DANIEL STUBBS 10/3/1962 58 59 59 092589137 Darin Sullivan 5/29/1965 56 56 56 232 025361836 EDWARD TARMEY 5/12/1954 67 67 67 711 593527709 JOSE B URTECHO 1/12/1965 56 56 57 1303 590031359 PATRICIA S VARNEY 12/4/1954 66 67 67 911 590435007 LEROY A WALTERS 2/4/1957 64 64 65 1210 594640401 PANSY WARWICK 11/27/1957 63 64 64 365 261715162 JEAN WENTWORTH 7/11/1962 59 59 59 532386392 Stephen Whitaker 5/7/1943 78 78 78 364 345480730 LEO WILLIAMS 11/1/1954 66 67 67 589056560 John E Williamson 12/7/1971 49 50 50 263112226 Matthew Zidar 8/31/1952 69 69 69 Address 1 Address 2 City State Zip/Postal Code Status Location Division 6529 NW 103 TERRACE PARKLAND FL 33076 Retiree 838 ARGONAUT ISLE DANIA BEACH FL 33004 Retiree 9205 NW 70TH PLACE TAMARAC FL 33321 Retiree 231 NORTH 68 AVENUE HOLLYWOOD FL 33024 Retiree 1294 NW 127 DRIVE SUNRISE FL 33323 Retiree 6731 NW 22 TERRACE FORT LAUDERDALE FL 33309 Retiree 2032 NE 21 COURT WILTON MANORS FL 33305 Retiree 1795 SE Clatter Bridge Rd Ocala FL 34471 Retiree 273 Dudala Way 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RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 2/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach 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Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Post Pension Retiree Under 65 Cigna New York Life RetireeLife Retiree Basic Life 3/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach General Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach General Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 10/1/2021 City of Dania Beach Police and Fire Pension Retiree Under 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 City of Dania Beach Police and Fire Pension Retiree Over 65Cigna New York Life RetireeLife Retiree Basic Life 1/1/2022 Benefit Amount Volume Client Premium Pre-Tax Deduction Post-Tax Deduction No. of Deductions Contribution No. of Contributions $2,500.00 $2,500.00 $0.00 $0.11 $0.22 12 $0.17 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.22 $0.45 12 $0.33 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $2,500.00 $2,500.00 $0.00 $0.00 $0.00 0 $0.50 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 $5,000.00 $5,000.00 $0.00 $0.00 $0.00 0 $1.00 12 Monthly Carrier Premium Carrier Adjustment Adjusted Carrier Premium Client Adjustment Admin Fee Admin Fee Adjustment Total Fee Individual Stop Loss $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.50 $0.00 $0.50 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 Individual Stop Loss AdjustmentAggregate Stop Loss Aggregate Stop Loss AdjustmentBill Date Generation Date Client ID Payment Tracker Amount Owed $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 Amount Paid Sp Date of Birth Age as of Plan Year Age as of Calendar Year Age as of Bill Date $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE Employee ID SSN First Name Middle Name Last Name Date of Birth Age as of Plan Year Start Age as of Calendar Start Age as of Bill Start 1860 133748432 RAFAEL ACOSTA 6/23/1979 42 42 42 1795 030468998 LORI ADAMS 1/16/1959 62 62 63 1809 104580750 RICKY A ALI 2/3/1976 45 45 46 1951 593592208 LOU ALPHONSE 11/2/1983 37 38 38 1958 590154460 ALEJANDRO AZCANO 7/29/1991 30 30 30 549 264917370 LOUIS BROWN 1/14/1967 54 54 55 1325 595629590 Joseph S Cangialosi 4/10/1974 47 47 48 1819 590653854 MAUDELINE CIGUENE 11/8/1981 39 40 40 1749 560594504 NATHAN JAMES COSTA 2/3/1980 41 41 42 1923 594642837 RUPERT CRAWFORD 11/30/1975 45 46 46 1806 590322274 WINDY DAMIS 1/24/1985 36 36 37 1425 590602516 FRANK L DIPAOLO 8/25/1980 41 41 41 1446 137620586 COLIN E DONNELLY 12/1/1967 53 54 54 1894 267733568 RICKEY DOTSON 3/24/1974 47 47 48 1787 262632685 DONALD LEE DRAKE 5/11/1961 60 60 60 1878 590484291 TAMARA DRUMMOND 4/4/1986 35 35 36 1992 592580462 TARIF RASHAD FLORENCE 4/27/1983 38 38 39 1202 427334848 MITCHELL V GRANT 11/7/1965 55 56 56 1239 591286620 DARREN D GREENE 8/8/1977 44 44 44 1700 498703431 MICHAEL HUCK 2/29/1972 49 49 50 1767 594761869 ANASTACIA RENEE HUGHES 2/6/1984 37 37 38 1820 595049001 RACHEL ICENHOUR 11/14/1990 30 31 31 1856 238455571 ANTHONY IFEDI 9/17/1984 37 37 37 1314 266499203 TAMMIE D JAMES 7/6/1963 58 58 58 1755 590085360 MEGAN JELASO 3/21/1986 35 35 36 1661 595341807 ANTOINE JOHNSON 12/13/1969 51 52 52 2013 266770217 KENNITH JOHNSON JR 2/14/1977 44 44 45 1890 595305239 CORY JOLLY 10/29/1984 36 37 37 1308 593272660 BENET JOSEPH 11/6/1958 62 63 63 1430 191469419 CHRISTINE A LOTTIER 8/8/1959 62 62 62 2027 591309395 DARRYL MCFARLANE 7/22/1978 43 43 43 947 261897771 DONIAL MCHELLON 12/8/1966 54 55 55 1937 592085509 GREGORY MCNEAL 1/10/1991 30 30 31 2022 605140173 KARLA MERCADO 10/15/1979 41 42 42 2025 772501841 FELICIA MILES 6/17/1983 38 38 38 1929 383706984 SHAWN PATRICK MURPHY 12/10/1957 63 64 64 1789 593090506 ELEANOR NORENA 12/8/1980 40 41 41 1797 589624137 SHERRY PECORARO 11/4/1978 42 43 43 1143 411190189 TERRY PETERSON 2/16/1960 61 61 62 1920 427496933 ALBERLEAN POLLARD 2/2/1984 37 37 38 1965 454412692 Michael Reyes 6/18/1974 47 47 47 1680 262997953 MICHAEL S RODRIGUEZ 1/13/1978 43 43 44 1682 584357577 RICHARD RODRIGUEZ 2/3/1970 51 51 52 1168 592853271 JOSE F SALGADO 9/30/1964 57 57 57 2017 100765008 DAVID SANABRIA 8/15/1987 34 34 34 1930 598302792 JULIO MANUEL SANTANA TORRES 5/18/1991 30 30 30 1321 595071093 JANICE L SAUNDERS 1/3/1960 61 61 62 1758 510627812 THOMAS SCHNEIDER 12/21/1957 63 64 64 1829 591879906 ADAM SEGAL 4/20/1971 50 50 51 2008 592411842 KEVIN N SINGH 12/17/1976 44 45 45 1939 266890936 CANDIDO SOSA-CRUZ 9/17/1975 46 46 46 1853 254887420 WILLIE SPENCER 6/29/1952 69 69 69 1343 592103000 TANIA A STEVENS 7/25/1966 55 55 55 1439 595206414 CORRY G TAYLOR 2/24/1973 48 48 49 1443 591243790 ERIC J WALTON 1/5/1976 45 45 46 1981 392026299 CASSANDRA WAREN 4/15/1985 36 36 37 1205 593662750 WILLIS B WASHINGTON JR 10/7/1973 47 48 48 1828 592213730 ANSON J.WESTBERRY 8/24/1989 32 32 32 1790 267552419 GEORGE WHITE 12/10/1961 59 60 60 1671 593919082 MARLON ZAPATA 6/16/1987 34 34 34 Address 1 Address 2 City State Zip/Postal Code Status Location Division 4051 SW 73 AVE Davie FL 33314 Active REC.ADM - Recreation/Administrative 6935 NW 16 Street Margate FL 33063 Active CTYA.ADM - City Attorney/Administrative 6863 NW 27 AVE Fort Lauderdale FL 33309 Active CD.CODE - Community Development/Code Compliance 225 NW 133RD STREET NORTH MIAMI FL 33168 Active PS.ST - Public Services/Streets 7410 NW 10TH COURT PLANTATION FL 33313 Active REC.BCH - Recreation/Beach 1304 NW 2 STREET APT. B DANIA BEACH FL 33004 Active PS.ST - Public Services/Streets 11571 NW 2nd Street Plantation FL 33325 Active PS.PKL - Public Services/Parks and Landscaping 301 Seminole Palms Drive Greenacres FL 33463 Active FIN.ADM - Finance/Administrative 2980 NW 106th Avenue CORAL SPRINGS FL 33065 Active PS.WP - Public Services/Water Facilities 1130 SW 7TH AVENUE Deerfield Beach FL 33441 Active PS.UT - Public Services/Utilities 1448 Holly Heights DR Apt 1 Fort Lauderdale FL 33304 Active CD.CODE - Community Development/Code Compliance 5308 NW 83RD WAY Coral Springs FL 33067 Active FIN.ADM - Finance/Administrative 5300 SW 30 Way Dania Beach FL 333126913 Active PS.ADM - Public Services/Administrative 1515 NW 82 ST Miami FL 33147 Active PKG.OPS - Parking/Operations 6413 PLUNKETT STREET HOLLYWOOD FL 33023 Active PS.UT - Public Services/Utilities 1490 Sheridan St.13 A Hollywood FL 33020 Active FIN.UT - Finance/Utilities 2641 NW 46th Avenue Lauderhill FL 33313 Active FIN.ADM - Finance/Administrative 4731 SW 66TH TERRACE DAVIE FL 33314 Active PS.PKL - Public Services/Parks and Landscaping 294 NW 13TH COURT DANIA BEACH FL 33004 Active PS.UT - Public Services/Utilities 307 NE 8TH CT POMPANO BEACH FL 33060 Active REC.BCH - Recreation/Beach 3540 NW 50TH AVE L110 LAUDERDALE LAKES FL 33319 Active CD.BD - Community Development/Building 17324 NW 10 ST Pembroke Pines FL 33029 Active FIN.UT - Finance/Utilities 10741 N Saratoga Dr.Cooper City FL 33026 Active REC.ADM - Recreation/Administrative 255 NW Tamara James Ave.DANIA BEACH FL 33004 Active CD.BD - Community Development/Building 3509 LAKESIDE DRIVE DAVIE FL 33328 Active FIN.ADM - Finance/Administrative 2254 Charleston St.HOLLYWOOD FL 33020 Active PS.ADM - Public Services/Administrative 19401 NW 24th AVE MIAMI FL 33056 Active REC.ADM - Recreation/Administrative 225 NW 133 ST Miami FL 33168 Active FIN.UT - Finance/Utilities 4010 SW 59TH TERRACE WEST PARK FL 33023 Active PS.ST - Public Services/Streets 8411 NW 17 COURT PEMBROKE PINES FL 33024 Active CM.ADM - City Manager/Administrative 8531 NW 41 Street Cooper City FL 33024 Active IS.ADM - Information Systems/Administrative 1535 SW 12 AVE APT 1 DANIA BEACH FL 33004 Active FIN.UT - Finance/Utilities 2430 NW 183RD STREET MIAMI GARDENS FL 33056 Active PS.ST - Public Services/Streets 832 Harbor Inn Drive Building 6 Coral Springs FL 33071 Active REC.ADM - Recreation/Administrative 2740 NW 11 Court Fort Lauderdale FL 33311 Active CD.CODE - Community Development/Code Compliance 5 DANBY PL BOYTON BEACH FL 33426 Active PS.WP - Public Services/Water Facilities 3905 JEFFERSON STREET HOLLYWOOD FL 33021 Active CD.ADM - Community Development/Administrative 901 SW 133 Avenue Davie FL 33325 Active FIN.UT - Finance/Utilities 4632 SW 37 AVENUE FORT LAUDERDALE FL 33312 Active CD.BD - Community Development/Building 3051 N.W. 30 Terrace OAKLAND PARK FL 33311 Active REC.ADM - Recreation/Administrative 4561 NE 4TH AVENUE POMPANO BEACH FL 33064 Active HR.ADM - Human Resources/Administrative 2428 Oak Gardens Lane Hollywood FL 33020 Active PS.ST - Public Services/Streets 7261 POLK ST HOLLYWOOD FL 33024 Active PS.UT - Public Services/Utilities 271 NORTHEAST 142 STREET NORTH MIAMI FL 33161 Active PS.PKL - Public Services/Parks and Landscaping 4304 NW 9TH AVE BOX 29 POMPANO BEACH FL 33064 Active PS.ST - Public Services/Streets 64 MADRID LN DAVIE FL 33324 Active PS.WP - Public Services/Water Facilities 1791 Lyons Road Apt. 206 Coconut Creek FL FL 33063 Active CD.BD - Community Development/Building 3370 NW 21 AVENUE OAKLAND PARK FL 33309 Active CLRK.ADM - City Clerk/Administrative 2412 NE 4 Street E Pompano Beach FL 33062 Active FIN.ADM - Finance/Administrative 223 NE 107 STREET MIAMI FL 33161 Active PS.FLT - Public Services/Fleet Maintenance 230 SW 30TH CT.MIAMI FL 33135 Active CM.ADM - City Manager/Administrative PO BOX 504 Fort Lauderdale FL 33302 Active FC.BM - Facilities Maintenance /Building Maintenan 2620 East Aragon Boulevard #2 SUNRISE FL 33313 Active FIN.ADM - Finance/Administrative 2519 Oak Garden Lane Hollywood FL 33020 Active PS.ST - Public Services/Streets 3230 NW 66TH STREET FORT LAUDERDALE FL 33309 Active CD.CODE - Community Development/Code Compliance 8235 Cassia Terrace Tamarac FL 33321 Active REC.ADM - Recreation/Administrative 9571 NW 21 MANOR SUNRISE FL 33322 Active PS.UT - Public Services/Utilities 3041 NW 30th Avenue Oakland Park FL 33311 Active CD.CODE - Community Development/Code Compliance 4500 NW 15 STREET LAUDERHILL FL 33313 Active CD.CODE - Community Development/Code Compliance 1161 NW 47TH TERRACE MIAMI FL 33127 Active PS.UT - Public Services/Utilities Entity Benefit Class Carrier Coverage Type Plan Tier Benefit Eff. Date Benefit Term. Date City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 5/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 2/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 3/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 1/1/2022 City of Dania Beach Full Time (Dept Heads)Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolEELife Voluntary Employee Life 10/1/2021 Benefit Amount Volume Client Premium Pre-Tax Deduction Post-Tax Deduction No. of Deductions Contribution No. of Contributions $100,000.00 $100,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $40,000.00 $40,000.00 $0.00 $0.00 $21.40 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $28.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $7.50 24 $0.00 0 $10,000.00 $10,000.00 $0.00 $0.00 $2.90 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $28.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $15.75 24 $0.00 0 $100,000.00 $100,000.00 $0.00 $0.00 $19.00 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $5.25 24 $0.00 0 $200,000.00 $200,000.00 $0.00 $0.00 $58.00 24 $0.00 0 $100,000.00 $100,000.00 $0.00 $0.00 $19.00 24 $0.00 0 $20,000.00 $20,000.00 $0.00 $0.00 $10.70 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $100,000.00 $100,000.00 $0.00 $0.00 $47.00 24 $0.00 0 $100,000.00 $100,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $28.50 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $3.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $7.50 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $3.50 24 $0.00 0 $100,000.00 $100,000.00 $0.00 $0.00 $47.00 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $43.50 24 $0.00 0 $90,000.00 $90,000.00 $0.00 $0.00 $9.45 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $26.75 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $16.05 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $15.75 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $43.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $7.50 24 $0.00 0 $100,000.00 $100,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $26.75 24 $0.00 0 $60,000.00 $60,000.00 $0.00 $0.00 $6.30 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $15.75 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $26.75 24 $0.00 0 $190,000.00 $190,000.00 $0.00 $0.00 $13.30 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $28.50 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $5.25 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $14.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $70.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $7.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $7.50 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $26.75 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $80.25 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $14.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $15.75 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $28.50 24 $0.00 0 $40,000.00 $40,000.00 $0.00 $0.00 $30.20 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $70.50 24 $0.00 0 $100,000.00 $100,000.00 $0.00 $0.00 $19.00 24 $0.00 0 $70,000.00 $70,000.00 $0.00 $0.00 $13.30 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $10.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $28.50 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $2.50 24 $0.00 0 $150,000.00 $150,000.00 $0.00 $0.00 $70.50 24 $0.00 0 $40,000.00 $40,000.00 $0.00 $0.00 $2.00 24 $0.00 0 Monthly Carrier Premium Carrier Adjustment Adjusted Carrier Premium Client Adjustment Admin Fee Admin Fee Adjustment Total Fee Individual Stop Loss $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $42.80 $0.00 $42.80 $0.00 $0.00 $0.00 $57.00 $0.00 $57.00 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $15.00 $0.00 $15.00 $0.00 $0.00 $0.00 $5.80 $0.00 $5.80 $0.00 $0.00 $0.00 $57.00 $0.00 $57.00 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $31.50 $0.00 $31.50 $0.00 $0.00 $0.00 $38.00 $0.00 $38.00 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $10.50 $0.00 $10.50 $0.00 $0.00 $0.00 $116.00 $0.00 $116.00 $0.00 $0.00 $0.00 $38.00 $0.00 $38.00 $0.00 $0.00 $0.00 $21.40 $0.00 $21.40 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $94.00 $0.00 $94.00 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $57.00 $0.00 $57.00 $0.00 $0.00 $0.00 $7.00 $0.00 $7.00 $0.00 $0.00 $0.00 $15.00 $0.00 $15.00 $0.00 $0.00 $0.00 $7.00 $0.00 $7.00 $0.00 $0.00 $0.00 $94.00 $0.00 $94.00 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $87.00 $0.00 $87.00 $0.00 $0.00 $0.00 $18.90 $0.00 $18.90 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $53.50 $0.00 $53.50 $0.00 $0.00 $0.00 $32.10 $0.00 $32.10 $0.00 $0.00 $0.00 $31.50 $0.00 $31.50 $0.00 $0.00 $0.00 $87.00 $0.00 $87.00 $0.00 $0.00 $0.00 $15.00 $0.00 $15.00 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $53.50 $0.00 $53.50 $0.00 $0.00 $0.00 $12.60 $0.00 $12.60 $0.00 $0.00 $0.00 $31.50 $0.00 $31.50 $0.00 $0.00 $0.00 $53.50 $0.00 $53.50 $0.00 $0.00 $0.00 $26.60 $0.00 $26.60 $0.00 $0.00 $0.00 $57.00 $0.00 $57.00 $0.00 $0.00 $0.00 $10.50 $0.00 $10.50 $0.00 $0.00 $0.00 $29.00 $0.00 $29.00 $0.00 $0.00 $0.00 $141.00 $0.00 $141.00 $0.00 $0.00 $0.00 $15.00 $0.00 $15.00 $0.00 $0.00 $0.00 $15.00 $0.00 $15.00 $0.00 $0.00 $0.00 $53.50 $0.00 $53.50 $0.00 $0.00 $0.00 $160.50 $0.00 $160.50 $0.00 $0.00 $0.00 $29.00 $0.00 $29.00 $0.00 $0.00 $0.00 $31.50 $0.00 $31.50 $0.00 $0.00 $0.00 $57.00 $0.00 $57.00 $0.00 $0.00 $0.00 $60.40 $0.00 $60.40 $0.00 $0.00 $0.00 $141.00 $0.00 $141.00 $0.00 $0.00 $0.00 $38.00 $0.00 $38.00 $0.00 $0.00 $0.00 $26.60 $0.00 $26.60 $0.00 $0.00 $0.00 $21.00 $0.00 $21.00 $0.00 $0.00 $0.00 $57.00 $0.00 $57.00 $0.00 $0.00 $0.00 $5.00 $0.00 $5.00 $0.00 $0.00 $0.00 $141.00 $0.00 $141.00 $0.00 $0.00 $0.00 $4.00 $0.00 $4.00 $0.00 $0.00 $0.00 Individual Stop Loss AdjustmentAggregate Stop Loss Aggregate Stop Loss AdjustmentBill Date Generation Date Client ID Payment Tracker Amount Owed $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 Amount Paid Sp Date of Birth Age as of Plan Year Age as of Calendar Year Age as of Bill Date $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE Employee ID SSN First Name Middle Name Last Name Date of Birth Age as of Plan Year Start Age as of Calendar Start Age as of Bill Start 1860 133748432 RAFAEL ACOSTA 6/23/1979 42 42 42 1809 104580750 RICKY A ALI 2/3/1976 45 45 46 1819 590653854 MAUDELINE CIGUENE 11/8/1981 39 40 40 1749 560594504 NATHAN JAMES COSTA 2/3/1980 41 41 42 1923 594642837 RUPERT CRAWFORD 11/30/1975 45 46 46 1806 590322274 WINDY DAMIS 1/24/1985 36 36 37 1202 427334848 MITCHELL V GRANT 11/7/1965 55 56 56 1239 591286620 DARREN D GREENE 8/8/1977 44 44 44 1700 498703431 MICHAEL HUCK 2/29/1972 49 49 50 1767 594761869 ANASTACIA RENEE HUGHES 2/6/1984 37 37 38 1314 266499203 TAMMIE D JAMES 7/6/1963 58 58 58 1661 595341807 ANTOINE JOHNSON 12/13/1969 51 52 52 2013 266770217 KENNITH JOHNSON JR 2/14/1977 44 44 45 1890 595305239 CORY JOLLY 10/29/1984 36 37 37 1430 191469419 CHRISTINE A LOTTIER 8/8/1959 62 62 62 2022 605140173 KARLA MERCADO 10/15/1979 41 42 42 2025 772501841 FELICIA MILES 6/17/1983 38 38 38 1929 383706984 SHAWN PATRICK MURPHY 12/10/1957 63 64 64 1789 593090506 ELEANOR NORENA 12/8/1980 40 41 41 1797 589624137 SHERRY PECORARO 11/4/1978 42 43 43 1143 411190189 TERRY PETERSON 2/16/1960 61 61 62 1168 592853271 JOSE F SALGADO 9/30/1964 57 57 57 1321 595071093 JANICE L SAUNDERS 1/3/1960 61 61 62 1439 595206414 CORRY G TAYLOR 2/24/1973 48 48 49 1981 392026299 CASSANDRA WAREN 4/15/1985 36 36 37 1205 593662750 WILLIS B WASHINGTON JR 10/7/1973 47 48 48 1790 267552419 GEORGE WHITE 12/10/1961 59 60 60 Address 1 Address 2 City State Zip/Postal Code Status Location Division 4051 SW 73 AVE Davie FL 33314 Active REC.ADM - Recreation/Administrative 6863 NW 27 AVE Fort Lauderdale FL 33309 Active CD.CODE - Community Development/Code Compliance 301 Seminole Palms Drive Greenacres FL 33463 Active FIN.ADM - Finance/Administrative 2980 NW 106th Avenue CORAL SPRINGS FL 33065 Active PS.WP - Public Services/Water Facilities 1130 SW 7TH AVENUE Deerfield Beach FL 33441 Active PS.UT - Public Services/Utilities 1448 Holly Heights DR Apt 1 Fort Lauderdale FL 33304 Active CD.CODE - Community Development/Code Compliance 4731 SW 66TH TERRACE DAVIE FL 33314 Active PS.PKL - Public Services/Parks and Landscaping 294 NW 13TH COURT DANIA BEACH FL 33004 Active PS.UT - Public Services/Utilities 307 NE 8TH CT POMPANO BEACH FL 33060 Active REC.BCH - Recreation/Beach 3540 NW 50TH AVE L110 LAUDERDALE LAKES FL 33319 Active CD.BD - Community Development/Building 255 NW Tamara James Ave.DANIA BEACH FL 33004 Active CD.BD - Community Development/Building 2254 Charleston St.HOLLYWOOD FL 33020 Active PS.ADM - Public Services/Administrative 19401 NW 24th AVE MIAMI FL 33056 Active REC.ADM - Recreation/Administrative 225 NW 133 ST Miami FL 33168 Active FIN.UT - Finance/Utilities 8411 NW 17 COURT PEMBROKE PINES FL 33024 Active CM.ADM - City Manager/Administrative 832 Harbor Inn Drive Building 6 Coral Springs FL 33071 Active REC.ADM - Recreation/Administrative 2740 NW 11 Court Fort Lauderdale FL 33311 Active CD.CODE - Community Development/Code Compliance 5 DANBY PL BOYTON BEACH FL 33426 Active PS.WP - Public Services/Water Facilities 3905 JEFFERSON STREET HOLLYWOOD FL 33021 Active CD.ADM - Community Development/Administrative 901 SW 133 Avenue Davie FL 33325 Active FIN.UT - Finance/Utilities 4632 SW 37 AVENUE FORT LAUDERDALE FL 33312 Active CD.BD - Community Development/Building 271 NORTHEAST 142 STREET NORTH MIAMI FL 33161 Active PS.PKL - Public Services/Parks and Landscaping 1791 Lyons Road Apt. 206 Coconut Creek FL FL 33063 Active CD.BD - Community Development/Building 2519 Oak Garden Lane Hollywood FL 33020 Active PS.ST - Public Services/Streets 8235 Cassia Terrace Tamarac FL 33321 Active REC.ADM - Recreation/Administrative 9571 NW 21 MANOR SUNRISE FL 33322 Active PS.UT - Public Services/Utilities 4500 NW 15 STREET LAUDERHILL FL 33313 Active CD.CODE - Community Development/Code Compliance Entity Benefit Class Carrier Coverage Type Plan Tier Benefit Eff. Date Benefit Term. Date City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 2/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolSpLife Voluntary Spouse Life 10/1/2021 Benefit Amount Volume Client Premium Pre-Tax Deduction Post-Tax Deduction No. of Deductions Contribution No. of Contributions $50,000.00 $50,000.00 $0.00 $0.00 $5.25 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $9.50 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $2.10 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $3.15 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $5.70 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $2.10 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $14.10 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $5.25 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $5.70 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $2.10 24 $0.00 0 $10,000.00 $10,000.00 $0.00 $0.00 $4.70 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $8.70 24 $0.00 0 $25,000.00 $25,000.00 $0.00 $0.00 $2.63 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $3.50 24 $0.00 0 $15,000.00 $15,000.00 $0.00 $0.00 $8.03 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $3.15 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $2.10 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $26.75 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $3.15 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $3.15 24 $0.00 0 $25,000.00 $25,000.00 $0.00 $0.00 $13.38 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $23.50 24 $0.00 0 $25,000.00 $25,000.00 $0.00 $0.00 $13.38 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $9.50 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $2.10 24 $0.00 0 $50,000.00 $50,000.00 $0.00 $0.00 $9.50 24 $0.00 0 $30,000.00 $30,000.00 $0.00 $0.00 $14.10 24 $0.00 0 Monthly Carrier Premium Carrier Adjustment Adjusted Carrier Premium Client Adjustment Admin Fee Admin Fee Adjustment Total Fee Individual Stop Loss $10.50 $0.00 $10.50 $0.00 $0.00 $0.00 $19.00 $0.00 $19.00 $0.00 $0.00 $0.00 $4.20 $0.00 $4.20 $0.00 $0.00 $0.00 $6.30 $0.00 $6.30 $0.00 $0.00 $0.00 $11.40 $0.00 $11.40 $0.00 $0.00 $0.00 $4.20 $0.00 $4.20 $0.00 $0.00 $0.00 $28.20 $0.00 $28.20 $0.00 $0.00 $0.00 $10.50 $0.00 $10.50 $0.00 $0.00 $0.00 $11.40 $0.00 $11.40 $0.00 $0.00 $0.00 $4.20 $0.00 $4.20 $0.00 $0.00 $0.00 $9.40 $0.00 $9.40 $0.00 $0.00 $0.00 $17.40 $0.00 $17.40 $0.00 $0.00 $0.00 $5.25 $0.00 $5.25 $0.00 $0.00 $0.00 $7.00 $0.00 $7.00 $0.00 $0.00 $0.00 $16.05 $0.00 $16.05 $0.00 $0.00 $0.00 $6.30 $0.00 $6.30 $0.00 $0.00 $0.00 $4.20 $0.00 $4.20 $0.00 $0.00 $0.00 $53.50 $0.00 $53.50 $0.00 $0.00 $0.00 $6.30 $0.00 $6.30 $0.00 $0.00 $0.00 $6.30 $0.00 $6.30 $0.00 $0.00 $0.00 $26.75 $0.00 $26.75 $0.00 $0.00 $0.00 $47.00 $0.00 $47.00 $0.00 $0.00 $0.00 $26.75 $0.00 $26.75 $0.00 $0.00 $0.00 $19.00 $0.00 $19.00 $0.00 $0.00 $0.00 $4.20 $0.00 $4.20 $0.00 $0.00 $0.00 $19.00 $0.00 $19.00 $0.00 $0.00 $0.00 $28.20 $0.00 $28.20 $0.00 $0.00 $0.00 Individual Stop Loss AdjustmentAggregate Stop Loss Aggregate Stop Loss AdjustmentBill Date Generation Date Client ID Payment Tracker Amount Owed $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 Amount Paid Sp Date of Birth Age as of Plan Year Age as of Calendar Year Age as of Bill Date $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE Employee ID SSN First Name Middle Name Last Name Date of Birth Age as of Plan Year Start Age as of Calendar Start Age as of Bill Start 1860 133748432 RAFAEL ACOSTA 6/23/1979 42 42 42 1951 593592208 LOU ALPHONSE 11/2/1983 37 38 38 549 264917370 LOUIS BROWN 1/14/1967 54 54 55 1923 594642837 RUPERT CRAWFORD 11/30/1975 45 46 46 1806 590322274 WINDY DAMIS 1/24/1985 36 36 37 1425 590602516 FRANK L DIPAOLO 8/25/1980 41 41 41 1446 137620586 COLIN E DONNELLY 12/1/1967 53 54 54 1878 590484291 TAMARA DRUMMOND 4/4/1986 35 35 36 1202 427334848 MITCHELL V GRANT 11/7/1965 55 56 56 1239 591286620 DARREN D GREENE 8/8/1977 44 44 44 1700 498703431 MICHAEL HUCK 2/29/1972 49 49 50 1767 594761869 ANASTACIA RENEE HUGHES 2/6/1984 37 37 38 1820 595049001 RACHEL ICENHOUR 11/14/1990 30 31 31 2013 266770217 KENNITH JOHNSON JR 2/14/1977 44 44 45 1890 595305239 CORY JOLLY 10/29/1984 36 37 37 947 261897771 DONIAL MCHELLON 12/8/1966 54 55 55 2022 605140173 KARLA MERCADO 10/15/1979 41 42 42 2025 772501841 FELICIA MILES 6/17/1983 38 38 38 1789 593090506 ELEANOR NORENA 12/8/1980 40 41 41 1797 589624137 SHERRY PECORARO 11/4/1978 42 43 43 1920 427496933 ALBERLEAN POLLARD 2/2/1984 37 37 38 1680 262997953 MICHAEL S RODRIGUEZ 1/13/1978 43 43 44 1168 592853271 JOSE F SALGADO 9/30/1964 57 57 57 2017 100765008 DAVID SANABRIA 8/15/1987 34 34 34 1343 592103000 TANIA A STEVENS 7/25/1966 55 55 55 1439 595206414 CORRY G TAYLOR 2/24/1973 48 48 49 1981 392026299 CASSANDRA WAREN 4/15/1985 36 36 37 1205 593662750 WILLIS B WASHINGTON JR 10/7/1973 47 48 48 Address 1 Address 2 City State Zip/Postal Code Status Location Division 4051 SW 73 AVE Davie FL 33314 Active REC.ADM - Recreation/Administrative 225 NW 133RD STREET NORTH MIAMI FL 33168 Active PS.ST - Public Services/Streets 1304 NW 2 STREET APT. B DANIA BEACH FL 33004 Active PS.ST - Public Services/Streets 1130 SW 7TH AVENUE Deerfield Beach FL 33441 Active PS.UT - Public Services/Utilities 1448 Holly Heights DR Apt 1 Fort Lauderdale FL 33304 Active CD.CODE - Community Development/Code Compliance 5308 NW 83RD WAY Coral Springs FL 33067 Active FIN.ADM - Finance/Administrative 5300 SW 30 Way Dania Beach FL 333126913 Active PS.ADM - Public Services/Administrative 1490 Sheridan St.13 A Hollywood FL 33020 Active FIN.UT - Finance/Utilities 4731 SW 66TH TERRACE DAVIE FL 33314 Active PS.PKL - Public Services/Parks and Landscaping 294 NW 13TH COURT DANIA BEACH FL 33004 Active PS.UT - Public Services/Utilities 307 NE 8TH CT POMPANO BEACH FL 33060 Active REC.BCH - Recreation/Beach 3540 NW 50TH AVE L110 LAUDERDALE LAKES FL 33319 Active CD.BD - Community Development/Building 17324 NW 10 ST Pembroke Pines FL 33029 Active FIN.UT - Finance/Utilities 19401 NW 24th AVE MIAMI FL 33056 Active REC.ADM - Recreation/Administrative 225 NW 133 ST Miami FL 33168 Active FIN.UT - Finance/Utilities 1535 SW 12 AVE APT 1 DANIA BEACH FL 33004 Active FIN.UT - Finance/Utilities 832 Harbor Inn Drive Building 6 Coral Springs FL 33071 Active REC.ADM - Recreation/Administrative 2740 NW 11 Court Fort Lauderdale FL 33311 Active CD.CODE - Community Development/Code Compliance 3905 JEFFERSON STREET HOLLYWOOD FL 33021 Active CD.ADM - Community Development/Administrative 901 SW 133 Avenue Davie FL 33325 Active FIN.UT - Finance/Utilities 3051 N.W. 30 Terrace OAKLAND PARK FL 33311 Active REC.ADM - Recreation/Administrative 2428 Oak Gardens Lane Hollywood FL 33020 Active PS.ST - Public Services/Streets 271 NORTHEAST 142 STREET NORTH MIAMI FL 33161 Active PS.PKL - Public Services/Parks and Landscaping 4304 NW 9TH AVE BOX 29 POMPANO BEACH FL 33064 Active PS.ST - Public Services/Streets 2620 East Aragon Boulevard #2 SUNRISE FL 33313 Active FIN.ADM - Finance/Administrative 2519 Oak Garden Lane Hollywood FL 33020 Active PS.ST - Public Services/Streets 8235 Cassia Terrace Tamarac FL 33321 Active REC.ADM - Recreation/Administrative 9571 NW 21 MANOR SUNRISE FL 33322 Active PS.UT - Public Services/Utilities Entity Benefit Class Carrier Coverage Type Plan Tier Benefit Eff. Date Benefit Term. Date City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 2/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 4/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 4/1/2022 City of Dania Beach Full Time (Dept Heads)Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 3/1/2022 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 City of Dania Beach Regular Full Time Cigna New York Life VolChildLife Voluntary Child Life 10/1/2021 Benefit Amount Volume Client Premium Pre-Tax Deduction Post-Tax Deduction No. of Deductions Contribution No. of Contributions $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 $5,000.00 $5,000.00 $0.00 $0.00 $0.43 24 $0.00 0 Monthly Carrier Premium Carrier Adjustment Adjusted Carrier Premium Client Adjustment Admin Fee Admin Fee Adjustment Total Fee Individual Stop Loss $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 $0.85 $0.00 $0.85 $0.00 $0.00 $0.00 Individual Stop Loss AdjustmentAggregate Stop Loss Aggregate Stop Loss AdjustmentBill Date Generation Date Client ID Payment Tracker Amount Owed $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 Amount Paid Sp Date of Birth Age as of Plan Year Age as of Calendar Year Age as of Bill Date $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE Employee ID SSN First Name Middle Name Last Name Date of Birth Age as of Plan Year Start Age as of Calendar Start Age as of Bill Start 1919 263976514 ERIC BROWN 6/20/1966 55 55 55 1975 262924459 Michael KENNETH Chen 4/11/1950 71 71 72 1425 590602516 FRANK L DIPAOLO 8/25/1980 41 41 41 1935 264734142 ANA M GARCIA 10/24/1961 59 60 60 1961 152386428 LINDA GONZALEZ 7/24/1963 58 58 58 1789 593090506 ELEANOR NORENA 12/8/1980 40 41 41 1943 147568493 FERNANDO RODRIGUEZ 4/28/1960 61 61 62 1758 510627812 THOMAS SCHNEIDER 12/21/1957 63 64 64 1939 266890936 CANDIDO SOSA-CRUZ 9/17/1975 46 46 46 Address 1 Address 2 City State Zip/Postal Code Status Location Division 601 NW 34 TERRACE LAUDERHILL FL 33311 Active REC.ADM - Recreation/Administrative 709 SW 13th St.Unit B Fort Lauderdale FL 33315 Active CRA.ADM - Community Redevelopment Agency/Administr 5308 NW 83RD WAY Coral Springs FL 33067 Active FIN.ADM - Finance/Administrative 9381 SW 51 TERRACE MIAMI FL 33165 Active CM.ADM - City Manager/Administrative 2811 MONTEVIDEO AVE COOPER CITY FL 33026 Active HR.ADM - Human Resources/Administrative 3905 JEFFERSON STREET HOLLYWOOD FL 33021 Active CD.ADM - Community Development/Administrative 5701 COLLINS AVENUE #1006 MIAMI BEACH FL 33140 Active PS.ADM - Public Services/Administrative 3370 NW 21 AVENUE OAKLAND PARK FL 33309 Active CLRK.ADM - City Clerk/Administrative 230 SW 30TH CT.MIAMI FL 33135 Active CM.ADM - City Manager/Administrative Entity Benefit Class Carrier Coverage Type Plan Tier Benefit Eff. Date Benefit Term. Date City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 City of Dania Beach Full Time (Dept Heads)Cigna New York Life LTD Long Term Disability 10/1/2021 Benefit Amount Volume Client Premium Pre-Tax Deduction Post-Tax Deduction No. of Deductions Contribution No. of Contributions $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 $5,000.00 $8,333.33 $0.00 $0.00 $0.00 24 $13.34 24 Monthly Carrier Premium Carrier Adjustment Adjusted Carrier Premium Client Adjustment Admin Fee Admin Fee Adjustment Total Fee Individual Stop Loss $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 $26.67 $0.00 $26.67 $0.00 $0.00 $0.00 Individual Stop Loss AdjustmentAggregate Stop Loss Aggregate Stop Loss AdjustmentBill Date Generation Date Client ID Payment Tracker Amount Owed $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 $0.00 $0.00 May-22 5/10/2022 420 FALSE $0.00 Amount Paid Sp Date of Birth Age as of Plan Year Age as of Calendar Year Age as of Bill Date $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE $0.00 0.00 FALSE FALSE