HomeMy WebLinkAboutInv# 165281585 - Fidelity Security Life Insurance Company - 07/26/2022eYe
BILLING PERIOD: JUN, 2022
COVERAGE TIER
SUIIAAAARY INVOICE FOR:
GROUP ID:
SUBGROUP ID:
INVOICE NUMBER:
The City of Dania Beach COBM
5000544
1001
1 65281 585
Emptoyee + 'l 58.33 s8.33
FULL MONTH TOTAL S8.33
CURRENT BILLING PERIOD TOTAL
PAYMENT IS DUE IN FULL UPON RECEIPT
THE INVOICE CALCULATION 15 BASED ON MEMBERSHIP AS OF 05I2OI2O22
PLEASE DETACH AND RETURN
s8.33
eYg Remit To: Fidetity Security Life lnsurance Co.
PO Box 632530
Cincinnati, OH 45263-2530
The City of Dania Beach COBRA
Linda Gonzate
100 W. Dania Beach Btvd.
Dania Beach, FL 33004
GROUP lD: 5000544
SUBGROUP lD: 1001
INVOICE NUMBER: 165281585
TOTAL INVOICE AAAOUNT DUE: 58.33
000000
FULL MONTH
TOTAL
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FULL ROST'R
RO6TER usTlNG FOil
DlLUttG PERjO:
rxvotcE xunBER:
ROSTER REPORT
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1652815t5 To view dependent members, please see the Enrollment Report at
evemed.com/eyemanaqe