HomeMy WebLinkAboutInv# 165526799 - Fidelity Security Life Insurance Company - 12/28/2022 (3)PAYMENT IS DUE IN FULL UPON RECEIPT
THE INVOICE CALCULATION IS BASED ON MEMBERSHIP AS OF 11/20/2022
PLEASE DETACH AND RETURN
Remit To:Fidelity Security Life Insurance Co.
PO Box 632530
Cincinnati,OH 45263-2530
The City of Dania Beach
Linda Gonzalez
100 W. Dania Beach Blvd.
Dania Beach, FL 33004
GROUP ID:5000543
SUBGROUP ID:1001
INVOICE NUMBER:165526799
TOTAL INVOICE AMOUNT DUE:$1,542.02
000000
SUMMARY INVOICE FOR:The City of Dania Beach
GROUP ID:5000543
SUBGROUP ID:1001
BILLING PERIOD: DEC, 2022 INVOICE NUMBER:165526799
FULL MONTH
COVERAGE TIER COUNT RATE TOTAL
Employee Only 99 $4.39 $434.61
Employee + 1 60 $8.33 $499.80
Employee + Family 52 $12.24 $636.48
FULL MONTH TOTAL $1,570.89
RETROACTIVE ADJUSTMENTS
Retro 10/2022 ($12.24)
Retro 11/2022 ($16.63)
RETRO ADJUSTMENT TOTAL ($28.87)
CURRENT BILLING PERIOD TOTAL $1,542.02