HomeMy WebLinkAboutInv# 2022-00000852 - FLORIDA MUNICIPAL INSURANCE TRUST - 10/20/2022TO:
SUBJECT:
Payment is due on or before 10-01-2022.
Dania Beach
Invoice for Insurance Programs
Please find the attached billing statement for 10-01-2022.
Please be sure to pay as billed; any adjustments will be made on the next month's
statement.
OF THE SUMMARY SHEET TO ACCOUNTSRECEIVABLE@FLCITIES.COM. THIS INFORMATION WILL ENSURE THAT THE FUNDS
If payment is not received on or before 10-20-2022 coverage is cancelled,
effective 12:01 AM 10-01-2022 and no benefits will be paid on behalf of participantsfor expenses incurred on or after 10-01-2022.
Please return a copy of the Billing Summary along with your payment.
ACH INSTRUCTIONS TO REMIT PAYMENT TO FMIT
BANK: CAPITAL CITY BANK, 217 N. MONROE ST., TALLAHASSEE, FL 32301
RTN#/ABA#: 063100688
ACCT#: 0032620701ACCT TYPE: CHECKINGACCT NAME: FLORIDA MUNICIPAL INSURANCE TRUSTREMEMBER WHEN MAKING ACH PAYMENTS TO THE FMIT, EMAIL THE CITY FH#, PAYMENT AMOUNT, AND A COPY
Please remember to advise the FLC when an employee terminates theiremployment. We MUST be notified WITHIN 30 DAYS of this event.
If you have any questions regarding your billing statement please callHealth Benefits at (800) 756-3042.
ARE APPLIED TO YOUR ACCOUNT IN A TIMELY MANNER
MAKE CHECKS PAYABLE TO:FLORIDA MUNICIPAL INSURANCE TRUSTP O BOX 1757
TALLAHASSEE, FL 32302-1757
ATTENTION MEMBERS
Printed Date: 10/24/2022
PREMIUMS
Medical Plan 2 Employee + 1 32 $49,538.56
Medical Plan 2 Employee + Family 45 $106,901.10
Medical Plan 2 Employee Only 85 $66,733.50
Medical Plan 5 Employee + 1 0 $0.00
Medical Plan 5 Employee + Family 0 $0.00
Medical Plan 5 Employee Only 4 $2,713.40
$225,886.56
:$225,779.64
:-$225,779.64
:$225,886.56
:$0.00
:$225,886.56
TERMED W/ADJ
DANIA BEACH
FMIT # FH0129
SUMMARY BILLING PAGE
COVERAGE
TOTAL DUE
Gen Date: 10-06-2022
BALANCE FORWARD
PAYMENTS
CURRENT PREMIUMS
ADJUSTMENTS
ADJUSTMENTS TOTAL
$0.00 $49,538.56
$0.00 $106,901.10
$0.00 $66,733.50
$0.00 $0.00
$0.00 $0.00
$0.00 $2,713.40
$0.00 $0.00
$0.00 $225,886.56
Due Date: 10-01-2022
STATUSCOVERAG PLAN NAME TIER PREMIUM ADJUSTMETOTAL Active RetireeACOSTARAFAELAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58 $177,348.43 $48,538.13 $225,886.56 TRUEADAMSLORIAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10ALPHONSELOUAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08ANAYAALEXANDRAAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10AZCANOALEJANDROAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10BALDIETOMMYAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
BATISTA CLAUDIA A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58BORDYKATIAAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10BORGOSLUISAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58BOUTSISEVEAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10BROWNERICAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58BROWNLOUISAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10BROWNRODRICKAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08
BROWNE JOHNATHAN A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08CANGIALOSIJOSEPHAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
CHEN MICHAEL A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08CIGUENEMAUDELINEAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58CLAYTONERIKAAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58COLLINSROGERAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10COOKRONALDAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58COSTANATHANAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58CRAWFORDRUPERTAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
CROSS JERRYLYN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10DAMISWINDYAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58DAVILAEDDAAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58DAVISJOYCEAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10DE JESUS GABRIEL A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08DIPAOLOFRANKAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58DONNELLYCOLINAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
DOTSON RICKEY A Medical Plan 2 Employee Only $785.10 $0.00 $785.10DRUMMONDTAMARAAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
EKLE ROBERT A Medical Plan 2 Employee Only $785.10 $0.00 $785.10FLORENCETARIFAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10GAINESTANEISHAAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10GARDNERKALAAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10GRANTMITCHELLAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08GREENEDARIUSAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08GREENEDARRENAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
HARRIS WILLIAM A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08HENLEYALICEAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
HIRSCH STACY A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08HOGGINSERNESTAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10HUCKMICHAELAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58HUGHESANASTACIAAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58ICENHOURRACHELAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10IFEDIANTHONYAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10IGLESIAS GUTICLAUDIO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
JACKSON JOHNATHAN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10JAMESTAMARAAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08
JAMES TAMMIE A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08JELASOMEGANAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58JOHNSONBRANDONAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10JOHNSON JR KENNITH A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08JOLLYCORYAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
JOSEPH PATRICK A Medical Plan 2 Employee Only $785.10 $0.00 $785.10KALLICHARANCARLAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
LAJOIE CORINNE A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08LARIOS IBARG IBEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10LAWSONRACHELLEAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58LIMAMARILANEAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10LOBOYAMILAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58LOTTIERCHRISTINEAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58MARTINRALPHAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
MARTINEZ GABRIEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10MCDOWELLKEITHAMedicalPlan 5 Employee Only $678.35 $0.00 $678.35
MCFARLANE DARRYL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10MCHELLONDONIALAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58MCLARENKRISTENAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08MCNABBKENNETHAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08
DANIA BEACH Due Date: 10-01-2022Gen Date: 10-06-2022EMPLOYEE NAME
Printed Date: 10/24/2022
MCNEAL GREGORY A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58MCPHEEJOYCEAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10MERCADOKARLAAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58MILESFELICIAAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58MYKOOSHANESAAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10NORENAELEANORAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58ODMANLAURENAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08OZAYDINDINCERAMedicalPlan 5 Employee Only $678.35 $0.00 $678.35PECORAROSHERRYAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
PEGUERO ULYSSES A Medical Plan 2 Employee Only $785.10 $0.00 $785.10PEIRCELOGANAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10PEREZFRANKAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08PERRYLEONARDAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10PETERSONTERRYAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08POLLARDALBERLEANAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58QUINTEROJOHNAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
REYES EDDIE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10RODRIGUEZFERNANDOAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
RODRIGUEZ HAROLD A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08RODRIGUEZMICHAELAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10RODRIGUEZRICHARDAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58SABINODEBORAHAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08SALGADOJOSEAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58SALVINOMARCOAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10SALZBENJAMINAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
SANTANA JULIO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10SAUNDERSJANICEAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08SCHNEIDERTHOMASAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08SEGALADAMAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58SHELEYCHERIEAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10SINGHKEVINAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10SINGHMAXINEAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
SOMERS HOWARD A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08SPEARMITZIEAMedicalPlan 5 Employee Only $678.35 $0.00 $678.35
SPENCER WILLIE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10STEVENSTANIAAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08TAYLORCORRYAMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08TERRAZASMONICAAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58THOMASAHMADAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58UROWBARBARAAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58VASTAMICHAELAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
WALTON ERIC A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58WASHINGTONWILLISAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
WEEKES KATHLEEN A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08WESTCOKENYAAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58WESTBERRYANSONAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10WHITEDEONAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10WHITEGEORGEAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10WILLIAMSDARIUSAMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58WRITERCYRUSAMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
ZAPATA MARLON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10ANSBRONOAHRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
BAKER ERIC R Medical Plan 2 Employee Only $785.10 $0.00 $785.10BERTUCCIOJOSEPHRMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08BROWNKENNETHRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10CARUSOBRUCERMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08CHANDLERCHRISTOPHERRMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
DARA MICHAEL R Medical Plan 2 Employee Only $785.10 $0.00 $785.10FELICETTYMARKRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
GARCIA GONZALO R Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58HANSENDONALDRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10HENGPETERRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10HUSOSKYJOSEPHRMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58JOHNSONANTHONYRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10JOHNSONSTANLEYRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10KENONFLOYDRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
LEXA JOHN R Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58LIEMBRUCERMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
LORBER RICHARD R Medical Plan 2 Employee Only $785.10 $0.00 $785.10MACEANGELINARMedicalPlan 2 Employee Only $785.10 $0.00 $785.10MARIANIJENNIFERRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10MCDONALDMARYRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10Printed Date: 10/24/2022
MUSTELIER ENRIQUE R Medical Plan 2 Employee Only $785.10 $0.00 $785.10PATELLAROLOUANNRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10PATTERSONDIANNARMedicalPlan 2 Employee Only $785.10 $0.00 $785.10PELLECERSERGIORMedicalPlan 2 Employee Only $785.10 $0.00 $785.10PHIPPSBRIANRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10RIVIEREJOSEPHRMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08RODRIGUEZJOSERMedicalPlan 2 Employee Only $785.10 $0.00 $785.10ROSEMARYRMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08ROSSLUISARMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
RUDBECK BENJAMIN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10RUETHPATRICIARMedicalPlan 2 Employee Only $785.10 $0.00 $785.10SATTERFIELDNICKIRMedicalPlan 2 Employee + 1 $1,548.08 $0.00 $1,548.08SIEBRICHARDRMedicalPlan 5 Employee Only $678.35 $0.00 $678.35SLADECURTISRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10SMITHMICHAELRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10SNELLARNOLDRMedicalPlan 2 Employee + Family $2,375.58 $0.00 $2,375.58
STUBBS DANIEL R Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08SULLIVANDARINRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
TARMEY LORI R Medical Plan 2 Employee Only $785.10 $0.00 $785.10TRAVAGLIO-W CHER R Medical Plan 2 Employee Only $785.10 $0.00 $785.10URTECHOJOSERMedicalPlan 2 Employee Only $785.10 $0.00 $785.10WALTERSIRISHRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10WARWICKPANSYRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10WENTWORTHJEANRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10WILLIAMSONJOHNRMedicalPlan 2 Employee Only $785.10 $0.00 $785.10
$225,886.56
Printed Date: 10/24/2022