HomeMy WebLinkAboutInv# 2022-00000925 - FLORIDA MUNICIPAL INSURANCE TRUST - 11/18/2022 (3)TO:
SUBJECT:
Please remember to advise the FLC when an employee terminates their
employment. We MUST be notified WITHIN 30 DAYS of this event.
If you have any questions regarding your billing statement please call
Health Benefits at (800) 756-3042.
ARE APPLIED TO YOUR ACCOUNT IN A TIMELY MANNER
MAKE CHECKS PAYABLE TO:
FLORIDA MUNICIPAL INSURANCE TRUST
P O BOX 1757
TALLAHASSEE, FL 32302-1757
ATTENTION MEMBERS
OF THE SUMMARY SHEET TO ACCOUNTSRECEIVABLE@FLCITIES.COM. THIS INFORMATION WILL ENSURE THAT THE FUNDS
If payment is not received on or before 11-20-2022 coverage is cancelled,
effective 12:01 AM 11-01-2022 and no benefits will be paid on behalf of participants
for expenses incurred on or after 11-01-2022.
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#: 0032620701
ACCT TYPE: CHECKING
ACCT NAME: FLORIDA MUNICIPAL INSURANCE TRUST
REMEMBER WHEN MAKING ACH PAYMENTS TO THE FMIT, EMAIL THE CITY FH#, PAYMENT AMOUNT, AND A COPY
Payment is due on or before 11-01-2022.
Dania Beach
Invoice for Insurance Programs
Please find the attached billing statement for 11-01-2022.
Please be sure to pay as billed; any adjustments will be made on the next month's
statement.
Printed Date: 11/22/2022
PREMIUMS ADJUSTMENTS TOTAL
Medical Plan 2 Employee + 1 32 $49,538.56 $1,548.08 $51,086.64
Medical Plan 2 Employee + Family 44 $104,525.52 $0.00 $104,525.52
Medical Plan 2 Employee Only 86 $67,518.60 $0.00 $67,518.60
Medical Plan 5 Employee + 1 0 $0.00 $0.00 $0.00
Medical Plan 5 Employee + Family 0 $0.00 $0.00 $0.00
Medical Plan 5 Employee Only 4 $2,713.40 $0.00 $2,713.40
$0.00 $0.00
$224,296.08 $1,548.08 $225,844.16
: $225,886.56
: $0.00
: $224,296.08
: $1,548.08
: $451,730.72TOTAL DUE
Gen Date: 10-26-2022
BALANCE FORWARD
PAYMENTS
CURRENT PREMIUMS
ADJUSTMENTS
TERMED W/ADJ
DANIA BEACH Due Date: 11-01-2022
FMIT # FH0129
SUMMARY BILLING PAGE
COVERAGE
Active $177,306.03
Retiree $48,538.13
STATUSCOVERAGE TYPEPLAN NAME TIER PREMIUM ADJUSTMENT TOTAL $225,844.16
ADAMS LORI A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
ANAYA ALEXANDRA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
AZCANO ALEJANDRO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
BORDY KATIA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
BOUTSIS EVE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
BROWN LOUIS A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
CANGIALOSI JOSEPH A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
CASERTA CHRISTINA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
COLLINS ROGER A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
CROSS JERRYLYN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
DAVIS JOYCE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
DOTSON RICKEY A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
DRUMMOND TAMARA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
EKLE ROBERT A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
GAINES TANEISHA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
GARDNER KALA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
HENLEY ALICE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
HENLEY MOKIETA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
HOGGINS ERNEST A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
ICENHOUR RACHEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
IFEDI ANTHONY A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
IGLESIAS GUTIERREZCLAUDIO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
JACKSON JOHNATHAN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
JOHNSON BRANDON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
JOSEPH PATRICK A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
KALLICHARAN CARL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
LARIOS IBARGUENIBEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
LIMA MARILANE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
MARTINEZ GABRIEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
MCDOWELL KEITH A Medical Plan 5 Employee Only $678.35 $0.00 $678.35
MCFARLANE DARRYL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
MCPHEE JOYCE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
MYKOO SHANESA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
OZAYDIN DINCER A Medical Plan 5 Employee Only $678.35 $0.00 $678.35
PEGUERO ULYSSES A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
PEIRCE LOGAN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
PERRY LEONARD A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
QUINTERO JOHN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
REYES EDDIE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
RODRIGUEZ FERNANDO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
RODRIGUEZ MICHAEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SALVINO MARCO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SALZ BENJAMIN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SANTANA JULIO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SHELEY CHERIE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SINGH KEVIN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SINGH MAXINE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SPEAR MITZIE A Medical Plan 5 Employee Only $678.35 $0.00 $678.35
SPENCER WILLIE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
VASTA MICHAEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
WESTBERRY ANSON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
WHITE DEON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
WHITE GEORGE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
WRITER CYRUS A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
ZAPATA MARLON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10
ANSBRO NOAH R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
BAKER ERIC R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
BROWN KENNETH R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
DARA MICHAEL R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
FELICETTY MARK R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
HANSEN DONALD R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
HENG PETER R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
JOHNSON ANTHONY R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
JOHNSON STANLEY R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
KENON FLOYD R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
LIEM BRUCE R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
LORBER RICHARD R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
MACE ANGELINA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
MARIANI JENNIFER R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
DANIA BEACH Due Date: 11-01-2022
Gen Date: 10-26-2022
EMPLOYEE NAME
Printed Date: 11/22/2022
MCDONALD MARY R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
MUSTELIER ENRIQUE R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
PATELLARO LOUANN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
PATTERSON DIANNA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
PELLECER SERGIO R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
PHIPPS BRIAN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
RODRIGUEZ JOSE R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
ROSS LUISA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
RUDBECK BENJAMIN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
RUETH PATRICIA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SIEB RICHARD R Medical Plan 5 Employee Only $678.35 $0.00 $678.35
SLADE CURTIS R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SMITH MICHAEL R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SOMERS PATRICIA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
SULLIVAN DARIN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
TARMEY LORI R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
TRAVAGLIO-WILLIAMSCHER R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
URTECHO JOSE R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
WALTERS IRISH R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
WENTWORTH JEAN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
WILLIAMSON JOHN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10
Printed Date: 11/22/2022