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Inv# 165320490 - Fidelity Security Life Insurance Company - 07/05/2022
FULL MONTH LIST EM Subscriber ID Last Name First Name Billing Tier Plan Rate Division Code Location Code Company Code 26265734500 ACOSTA RAFAEL Employee + Family Benefit Level 1 $12.24 26265741800 Adams Laura Employee Only Benefit Level 1 $4.39 26265766300 ADAMS LORI Employee Only Benefit Level 1 $4.39 26265731400 ALI RICKY Employee + Family Benefit Level 1 $12.24 26265784900 ALPHONSE LOU Employee + 1 Benefit Level 1 $8.33 26918422000 ANAYA ALEXANDRA Employee Only Benefit Level 1 $4.39 26265753100 ANSBRO THOMAS Employee + Family Benefit Level 1 $12.24 27619023300 AZCANO ALEJANDRO Employee Only Benefit Level 1 $4.39 26265756800 BAKER ERIC Employee Only Benefit Level 1 $4.39 26265758800 BAKER JAMES Employee Only Benefit Level 1 $4.39 26265787900 BALDIE TOMMY Employee + Family Benefit Level 1 $12.24 26265744800 BERNARDO MICHAEL Employee + 1 Benefit Level 1 $8.33 27551170300 Bertino Barbara Employee Only Benefit Level 1 $4.39 26265772700 BERTUCCIO JOSEPH Employee + 1 Benefit Level 1 $8.33 26265752100 BLOCKER CHRISTY Employee Only Benefit Level 1 $4.39 26265750000 Blust James Employee + 1 Benefit Level 1 $8.33 26265744200 BOLTON CHESTER Employee Only Benefit Level 1 $4.39 26265784500 BORDY KATIA Employee Only Benefit Level 1 $4.39 26265793500 Borgos Luis Employee + 1 Benefit Level 1 $8.33 26265734000 BOUTSIS EVE Employee Only Benefit Level 1 $4.39 26265761200 BRANDES GLORIA Employee + 1 Benefit Level 1 $8.33 26265740100 BRAVE JOANN Employee Only Benefit Level 1 $4.39 26265791500 Brown Kenneth Employee Only Benefit Level 1 $4.39 26265754300 BROWN LOUIS Employee Only Benefit Level 1 $4.39 26265755200 BROWN MICHAEL Employee + 1 Benefit Level 1 $8.33 26265783800 BROWN RODRICK Employee + 1 Benefit Level 1 $8.33 26265753200 BROWN ERIC Employee + Family Benefit Level 1 $12.24 27498160300 BROWNE JOHNATHAN Employee + 1 Benefit Level 1 $8.33 26265792000 Cangialosi Joseph Employee Only Benefit Level 1 $4.39 26265735800 CARUSO BRUCE Employee + 1 Benefit Level 1 $8.33 26265739500 CASASANTA DAVID Employee + Family Benefit Level 1 $12.24 26265786600 Chandler Christopher Employee + Family Benefit Level 1 $12.24 INVOICE NUMBER:165281479 To view dependent members, please see the Enrollment Report at eyemed.com/eyemanage ROSTER REPORT FULL ROSTER ROSTER LISTING FOR:The City of Dania Beach BILLING PERIOD:June, 2022 26265749600 Chen Michael Employee + 1 Benefit Level 1 $8.33 26265792500 CHERIAN DANIEL Employee + 1 Benefit Level 1 $8.33 27431564600 Chong Johann Employee + Family Benefit Level 1 $12.24 26265778100 CIGUENE MAUDELINE Employee + Family Benefit Level 1 $12.24 26265757500 CLAYTON ERIKA Employee + Family Benefit Level 1 $12.24 26265786300 Collins Roger Employee Only Benefit Level 1 $4.39 26265770200 Cook Dorothy Employee Only Benefit Level 1 $4.39 26265787600 COOK RONALD Employee + Family Benefit Level 1 $12.24 26265771800 COSTA NATHAN Employee + Family Benefit Level 1 $12.24 26265754100 CRANDON FRANK Employee + 1 Benefit Level 1 $8.33 26265788400 CRAWFORD RUPERT Employee + Family Benefit Level 1 $12.24 26265743800 CROSS JERRYLYN Employee Only Benefit Level 1 $4.39 26265776000 DAMIS WINDY Employee + Family Benefit Level 1 $12.24 27304666100 Dara Michael Employee Only Benefit Level 1 $4.39 26265788900 DAVILA EDDA Employee + Family Benefit Level 1 $12.24 26265766900 Davis Joyce Employee Only Benefit Level 1 $4.39 26265737000 DE JESUS Gabriel Employee + Family Benefit Level 1 $12.24 26265751400 DENNY NANCI Employee Only Benefit Level 1 $4.39 26265777700 DIPAOLO FRANK Employee + Family Benefit Level 1 $12.24 26265736100 DONNELLY COLIN Employee + Family Benefit Level 1 $12.24 26265763800 DOTSON RICKEY Employee Only Benefit Level 1 $4.39 26265748600 DRAKE DONALD Employee + 1 Benefit Level 1 $8.33 26265776900 DRUMMOND TAMARA Employee Only Benefit Level 1 $4.39 26265764600 DUBISKY WILLIAM Employee + 1 Benefit Level 1 $8.33 27498159900 EKLE ROBERT Employee Only Benefit Level 1 $4.39 26265782200 FLORENCE TARIF Employee Only Benefit Level 1 $4.39 26265765400 FONDO GAIL Employee Only Benefit Level 1 $4.39 26265790200 GAINES TANEISHA Employee Only Benefit Level 1 $4.39 26265759600 GARCIA GONZALO Employee + Family Benefit Level 1 $12.24 26265764100 GARDNER EULA Employee Only Benefit Level 1 $4.39 26265789700 GARDNER KALA Employee + Family Benefit Level 1 $12.24 26265732300 Gennaro Joseph Employee Only Benefit Level 1 $4.39 26265732500 Giaquinto Ralph Employee + 1 Benefit Level 1 $8.33 26265770400 GILMOND RUSSELL Employee Only Benefit Level 1 $4.39 26265741600 GOODMAN THOMAS Employee + Family Benefit Level 1 $12.24 26265760000 Grammer Thomas Employee Only Benefit Level 1 $4.39 26265769700 GRANT MITCHELL Employee + 1 Benefit Level 1 $8.33 26265766500 Green Jack Employee Only Benefit Level 1 $4.39 26265779500 GREENE DARREN Employee + Family Benefit Level 1 $12.24 26265733600 Hansen Donald Employee + 1 Benefit Level 1 $8.33 26265764900 HARRIS WILLIAM Employee + 1 Benefit Level 1 $8.33 26265740800 HENLEY ALICE Employee Only Benefit Level 1 $4.39 26265769300 Hess Robert Employee + 1 Benefit Level 1 $8.33 27523150200 HIRSCH STACY Employee + 1 Benefit Level 1 $8.33 26265747100 HOLDEN LlOYD Employee + 1 Benefit Level 1 $8.33 26265770900 HUCK MICHAEL Employee + Family Benefit Level 1 $12.24 26265788700 HUGHES ANASTACIA Employee + Family Benefit Level 1 $12.24 26265747600 HUMPHREY JAMES Employee + 1 Benefit Level 1 $8.33 26265752700 HUSOSKY JOSEPH Employee + Family Benefit Level 1 $12.24 26265789100 ICENHOUR RACHEL Employee + Family Benefit Level 1 $12.24 26265742400 IFEDI ANTHONY Employee Only Benefit Level 1 $4.39 27644267300 IGLESIAS GUTIERREZ CLAUDIO Employee Only Benefit Level 1 $4.39 26265787400 JACKSON JOHNATHAN Employee Only Benefit Level 1 $4.39 26265759300 JAMES TAMMIE Employee + 1 Benefit Level 1 $8.33 26265784600 JAMES TAMARA Employee + 1 Benefit Level 1 $8.33 26265775500 JELASO MEGAN Employee + Family Benefit Level 1 $12.24 26265774300 JOHNSON BRANDON Employee Only Benefit Level 1 $4.39 26265787100 JOHNSON STANLEY Employee Only Benefit Level 1 $4.39 26265759000 JOHNSON ANTHONY Employee Only Benefit Level 1 $4.39 26265742000 JOHNSON CHARLENE Employee + 1 Benefit Level 1 $8.33 26265791600 JOHNSON ANTOINE Employee Only Benefit Level 1 $4.39 27371199000 JOHNSON JR KENNITH Employee + 1 Benefit Level 1 $8.33 26265791100 JOLLY CORY Employee + Family Benefit Level 1 $12.24 26265738400 JONES KRISTEN Employee Only Benefit Level 1 $4.39 26265782700 JOSEPH PATRICK Employee Only Benefit Level 1 $4.39 26265784100 JOSEPH BENET Employee + 1 Benefit Level 1 $8.33 26265737900 KALLICHARAN CARL Employee Only Benefit Level 1 $4.39 26265751000 KENON FLOYD Employee Only Benefit Level 1 $4.39 26265747000 KIMMICH ROBERT Employee + 1 Benefit Level 1 $8.33 26265762000 KIRBY DONNA Employee + 1 Benefit Level 1 $8.33 26265738300 KOCH KENNETH Employee Only Benefit Level 1 $4.39 26265765000 LAJOIE CORINNE Employee Only Benefit Level 1 $4.39 26265752400 LAND KENNETH Employee + 1 Benefit Level 1 $8.33 26265793700 LARIOS IBARGUEN IBEL Employee Only Benefit Level 1 $4.39 26265752800 LEXA JOHN Employee + Family Benefit Level 1 $12.24 26265744500 Liem Bruce Employee Only Benefit Level 1 $4.39 27712664100 Lima Marilane Employee Only Benefit Level 1 $4.39 26265736600 Lorber Richard Employee Only Benefit Level 1 $4.39 26265739100 LOTTIER CHRISTINE Employee + Family Benefit Level 1 $12.24 26265754500 MACE EUGENE Employee + Family Benefit Level 1 $12.24 26265767100 MARIANI MARK Employee + Family Benefit Level 1 $12.24 26265730200 Martin Ralph Employee + Family Benefit Level 1 $12.24 26265775100 MARTINEZ GABRIEL Employee Only Benefit Level 1 $4.39 26265766100 MASON LINDA Employee Only Benefit Level 1 $4.39 26265748300 MCDONALD MARY Employee Only Benefit Level 1 $4.39 27344168300 MCDOWELL KEITH Employee Only Benefit Level 1 $4.39 27551170900 MCFARLANE DARRYL Employee Only Benefit Level 1 $4.39 26265747300 MCHELLON DONIAL Employee + Family Benefit Level 1 $12.24 26265774800 McLaren Kristen Employee Only Benefit Level 1 $4.39 26265760800 McNabb Kenneth Employee + 1 Benefit Level 1 $8.33 26265780800 MCNEAL GREGORY Employee + Family Benefit Level 1 $12.24 27551171500 MERCADO KARLA Employee + Family Benefit Level 1 $12.24 26265751900 MIKES ROBERT Employee Only Benefit Level 1 $4.39 27571061000 MILES FELICIA Employee + Family Benefit Level 1 $12.24 26265751700 Miller Miles Employee Only Benefit Level 1 $4.39 26265753400 Molina Debbie Employee Only Benefit Level 1 $4.39 26340914900 Morrell Paula Employee + 1 Benefit Level 1 $8.33 26265773300 MORRIS GLENN Employee + 1 Benefit Level 1 $8.33 26265753600 Mulford James Employee Only Benefit Level 1 $4.39 26265773500 MUSTELIER JR ENRIQUE Employee Only Benefit Level 1 $4.39 26265785200 MYKOO SHANESA Employee Only Benefit Level 1 $4.39 26265783200 NORENA ELEANOR Employee + Family Benefit Level 1 $12.24 26265758300 ODMAN LAUREN Employee + 1 Benefit Level 1 $8.33 26265794800 ORLANDO DOMINIC Employee + 1 Benefit Level 1 $8.33 26265793100 OSTROFSKY WARREN Employee + Family Benefit Level 1 $12.24 26265786100 Ozaydin Dincer Employee Only Benefit Level 1 $4.39 27146264200 Palm Grace Employee Only Benefit Level 1 $4.39 26265768900 PATELLARO LOU ANN Employee Only Benefit Level 1 $4.39 26265758100 PATTERSON DIANNA Employee Only Benefit Level 1 $4.39 26265774500 PECORARO SHERRY Employee + Family Benefit Level 1 $12.24 26265773100 PEGUERO ULYSSES Employee Only Benefit Level 1 $4.39 26265776400 PEIRCE LOGAN Employee Only Benefit Level 1 $4.39 26265740600 PELLECER SERGIO Employee Only Benefit Level 1 $4.39 26265774100 PEREZ FRANK Employee + 1 Benefit Level 1 $8.33 26265772200 PERRY LEONARD Employee Only Benefit Level 1 $4.39 26265769600 PETERSON TERRY Employee + 1 Benefit Level 1 $8.33 26265749500 Pink Nelson Employee + 1 Benefit Level 1 $8.33 26265770000 POLLARD ALBERLEAN Employee + Family Benefit Level 1 $12.24 27475095000 QUINTERO JOHN Employee Only Benefit Level 1 $4.39 26265791900 REYES EDDIE Employee + 1 Benefit Level 1 $8.33 26265770300 Reyes Michael Employee Only Benefit Level 1 $4.39 26265735300 Rigo Rudolf Employee + 1 Benefit Level 1 $8.33 26265763100 RIVIERE JOSEPH Employee + 1 Benefit Level 1 $8.33 26265745600 Roberson Charlene Employee + 1 Benefit Level 1 $8.33 26265750100 RODRIGUEZ MICHAEL Employee + Family Benefit Level 1 $12.24 26265778500 RODRIGUEZ HAROLD Employee + 1 Benefit Level 1 $8.33 26265737300 RODRIGUEZ FERNANDO Employee Only Benefit Level 1 $4.39 26265745100 Rodriguez Jose Employee Only Benefit Level 1 $4.39 26265773800 RODRIGUEZ RICHARD Employee + Family Benefit Level 1 $12.24 26265757000 ROSE PERRY Employee + Family Benefit Level 1 $12.24 26265765700 ROSS FRANK Employee + 1 Benefit Level 1 $8.33 26265761500 RUETH RICHARD Employee + 1 Benefit Level 1 $8.33 26265756100 SABINO DEBORAH Employee + 1 Benefit Level 1 $8.33 26265782500 SALGADO JOSE Employee + Family Benefit Level 1 $12.24 26265755700 Salvino Marco Employee Only Benefit Level 1 $4.39 27453488400 SANABRIA DAVID Employee + Family Benefit Level 1 $12.24 27431566000 SANCHEZ CLAUDIA Employee + 1 Benefit Level 1 $8.33 26265792200 SANTANA TORRES JULIO Employee Only Benefit Level 1 $4.39 26265767400 SATTERFIELD NICKI Employee + 1 Benefit Level 1 $8.33 26265789400 SAUNDERS JANICE Employee + 1 Benefit Level 1 $8.33 26265745200 SAVAGE JAMES Employee + 1 Benefit Level 1 $8.33 26265771300 SCHNEIDER THOMAS Employee + 1 Benefit Level 1 $8.33 26265780600 SEGAL ADAM Employee + Family Benefit Level 1 $12.24 26265747900 SHELEY CHERIE Employee Only Benefit Level 1 $4.39 26505006400 Singh Maxine Employee Only Benefit Level 1 $4.39 26265746000 SLADE CURTIS Employee Only Benefit Level 1 $4.39 26265753500 SMITH MICHAEL Employee Only Benefit Level 1 $4.39 26265762500 Snell Arnold Employee + Family Benefit Level 1 $12.24 26265792800 SOMERS HOWARD Employee + 1 Benefit Level 1 $8.33 26265743300 SPENCER WILLIE Employee + 1 Benefit Level 1 $8.33 26265733300 STEINER MURRAY Employee Only Benefit Level 1 $4.39 26265781200 STEVENS TANIA Employee + 1 Benefit Level 1 $8.33 26265753700 STUBBS DANIEL Employee + 1 Benefit Level 1 $8.33 26265795200 Sullivan Darin Employee Only Benefit Level 1 $4.39 26265742900 TARMEY EDWARD Employee + 1 Benefit Level 1 $8.33 26265790400 TAYLOR CORRY Employee + Family Benefit Level 1 $12.24 26265781900 TERRAZAS MONICA Employee + Family Benefit Level 1 $12.24 26265748900 THOMAS AHMAD Employee + Family Benefit Level 1 $12.24 26265750700 TUBRIDY THOMAS Employee + 1 Benefit Level 1 $8.33 26265733000 UROW BARBARA Employee + 1 Benefit Level 1 $8.33 26340925000 URTECHO JOSE Employee Only Benefit Level 1 $4.39 26265737500 VASTA MICHAEL Employee Only Benefit Level 1 $4.39 26265776600 WALTERS LEROY Employee + 1 Benefit Level 1 $8.33 26265779300 WALTON ERIC Employee + Family Benefit Level 1 $12.24 26265769400 WAREN CASSANDRA Employee Only Benefit Level 1 $4.39 26265788200 WARWICK PANSY Employee Only Benefit Level 1 $4.39 26265785400 WASHINGTON JR WILLIS Employee + Family Benefit Level 1 $12.24 26265794500 WEEKES KATHLEEN Employee + 1 Benefit Level 1 $8.33 26265746700 WENTWORTH JEAN Employee Only Benefit Level 1 $4.39 26265760300 WEST COKENYA Employee + Family Benefit Level 1 $12.24 26265781600 WESTBERRY ANSON Employee Only Benefit Level 1 $4.39 26265771500 Whitaker Stephen Employee Only Benefit Level 1 $4.39 26265763500 WHITE GEORGE Employee Only Benefit Level 1 $4.39 26265746500 WHITE DEON Employee Only Benefit Level 1 $4.39 26265768600 WILLIAMS LEO Employee + 1 Benefit Level 1 $8.33 26265778800 Williams Darius Employee + Family Benefit Level 1 $12.24 26265775300 WRITER CYRUS Employee Only Benefit Level 1 $4.39 26265785800 ZAPATA MARLON Employee Only Benefit Level 1 $4.39 26265750300 Zidar Matthew Employee + 1 Benefit Level 1 $8.33 Location Total: $1,606.26 Full Month Total: $1,606.26 RETRO ADJUSTMENTS LIST EM Subscriber ID Last Name First Name Plan Start Period Date End Period Date Retro Period Rate Division Code Location Code Company Code 26265779100 GAITHER TIMOTHY Benefit Level 1 04/01/2022 04/30/2022 04/2022 ($8.33) Total Retro Adjustments for 04/2022 ($8.33) 26265779100 GAITHER TIMOTHY Benefit Level 1 05/01/2022 05/31/2022 05/2022 ($8.33) Total Retro Adjustments for 05/2022 ($8.33) Total Retro Adjustments for the Month of June, 2022 ($16.66) INVOICE NUMBER:165281479 To view dependent members, please see the Enrollment Report at eyemed.com/eyemanage ROSTER REPORT FULL ROSTER ROSTER LISTING FOR:The City of Dania Beach BILLING PERIOD:June, 2022