HomeMy WebLinkAboutInv# 165698593 - Fidelity Security Life Insurance Company - 04/30/2023 (2)SUMMARY INVOICE FOR:
INVOICE NUMBER:
SUBGROUP ID:
GROUP ID:
BILLING PERIOD:April, 2023
The City of Dania Beach
5000543
1001
165698593
FULL MONTH
COVERAGE TIER COUNT RATE TOTAL
Benefit Level 1
Employee Only 101 $4.39 $443.39
Employee + 1 66 $8.33 $549.78
Employee + Family 48 $12.24 $587.52
FULL MONTH TOTAL $1,580.69
RETROACTIVE ADJUSTMENTS
Retro 03/2023 $16.66
RETRO ADJUSTMENT TOTAL $16.66
CURRENT BILLING PERIOD TOTAL $1,597.35
FIDELITY SECURITY LIFE INSURANCE CO.PO BOX 632530CINCINNATI OH 45263-2530
Remit To:
GROUP ID:
SUBGROUP ID:
INVOICE NUMBER:
TOTAL INVOICE AMOUNT DUE:
5000543
1001
165698593
$1,597.35
THE CITY OF DANIA BEACHLINDA GONZALEZ100 W. DANIA BEACH BLVD.DANIA BEACH FL 33004
PAYMENT IS DUE IN FULL UPON RECEIPTTHE INVOICE CALCULATION IS BASED ON MEMBERSHIP AS OF 03/20/23PLEASE DETACH AND RETURN
Forwarding Service Requested
THE CITY OF DANIA BEACHLINDA GONZALEZ100 W. DANIA BEACH BLVD.DANIA BEACH FL 33004
1,470
EyeMed4000 LUXOTTICA PLMASON OH 45040-8114
J671 [1,470] 2 of 3
[DM-]
20230324B05J6713300 38195
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