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Inv# 2023-00000410 - FLORIDA MUNICIPAL INSURANCE TRUST - 05/19/2023 (3)
Medical Details Summary Cover TO: Dania Beach SUBJECT: Invoice for Insurance Programs Please find the attached billing statement for 05-01-2023. Please be sure to pay as billed; any adjustments will be made on the next month's statement. Payment is due on or before 05-01-2023. If payment is not received on or before 05-20-2023 coverage is cancelled, effective 12:01 AM 05-01-2023 and no benefits will be paid on behalf of participants for expenses incurred on or after 05-01-2023. 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 OF THE SUMMARY SHEET TO ACCOUNTSRECEIVABLE@FLCITIES.COM. THIS INFORMATION WILL ENSURE THAT THE FUNDS 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 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. DANIA BEACH Due Date: 05-01-2023 FMIT # FH0129 SUMMARY BILLING PAGE COVERAGE PREMIUMS ADJUSTMENTS TOTAL Medical Plan 2 Employee + 1 Employee + Family Employee Only Plan 5 TERMED W/ADJ May Due BALANCE FORWARD : PAYMENTS Mar Paid CURRENT PREMIUMS TOTAL DUE Gen Date: 04-24-2023 April Paid EMPLOYEE NAME STATUS COVERAGE TYPE PLAN NAME TIER PREMIUM ADJUSTMENT ACOSTA RAFAEL A ADAMS LORI ALI RICKY ALPHONSE LOU ANAYA ALEXANDRA ANSBRO NOAH R AZCANO ALEJANDRO BAKER ERIC BALDIE TOMMY BATISTA CLAUDIA BERTUCCIO JOSEPH BORDY KATIA BOUTSIS EVE BROWN KENNETH LOUIS RODRICK BROWNE JOHNATHAN CANGIALOSI CARPENTER MICHAEL CARUSO BRUCE CASERTA CHRISTINA CHANDLER CHRISTOPHER CHEN CLAYTON ERIKA COLLINS ROGER COOK RONALD COSTA NATHAN CRAWFORD RUPERT CROSS JERRYLYN DAMIS WINDY DARA DAVILA EDDA DAVIS JOYCE DE JESUS GABRIEL DIPAOLO FRANK DOMINGUEZ MARIA DONNELLY COLIN DOTSON RICKEY DRUMMOND TAMARA EDGE CHARLES EKLE ROBERT FELICETTY MARK GAINES TANEISHA GARCIA GONZALO GARDNER KALA GONZAGA LIVANIA GRANT MITCHELL GREENE DARIUS DARREN HANSEN DONALD HARRIS WILLIAM HENG PETER HENLEY MOKIETA HIRSCH STACY HOGGINS ERNEST HUCK HUGHES ANASTACIA HUSOSKY ICENHOUR RACHEL IFEDI ANTHONY IGLESIAS GUTIERREZ CLAUDIO JACKSON JAMES TAMMIE JELASO MEGAN JOHNSON ANTOINE BRANDON STANLEY JOHNSON JR KENNITH JOLLY CORY PATRICK KALLICHARAN CARL KENON FLOYD KNUDSON THEODORE LAJOIE CORINNE LARIOS IBARGUEN IBEL LAVINA ARMENIO LAWSON RACHELLE LEWELLEN LEXA JOHN LIEM LIMA MARILANE LOBO YAMIL LORBER RICHARD LOTTIER CHRISTINE MACE ANGELINA MARIANI JENNIFER MARTIN RALPH MARTINEZ MCDONALD MARVIN MARY MCDOWELL KEITH MCFARLANE DARRYL MCHELLON DONIAL MCLAREN KRISTEN MCNABB MCNEAL GREGORY MCPHEE MERCADO KARLA MIEREZ ANN MIRANDA SHANESA MUSTELIER JR. ENRIQUE NEAL TODD NORENA ELEANOR OZAYDIN DINCER PATELLARO LOUANN PATTERSON DIANNA PECORARO SHERRY PEGUERO ULYSSES PEIRCE LOGAN PELLECER SERGIO PEREZ PERRY LEONARD PETERSON TERRY PHIPPS BRIAN POLLARD ALBERLEAN QUINTERO REYES EDDIE RIERA ELORA RIVIERE RODRIGUEZ FERNANDO HAROLD JOSE ROSE ROSS LUISA RUDBECK BENJAMIN RUETH PATRICIA RYAN ARCHIBALD SABINO DEBORAH SALGADO SALVINO MARCO SANTANA JULIO SATTERFIELD NICKI SAUNDERS JANICE SEGAL ADAM SHAHRYAR MICHELLE SHELEY CHERIE SIEB SINGH KEVIN MAXINE SLADE CURTIS SMITH SNELL ARNOLD SOMERS SPEAR MITZIE SPENCER ANGELA WILLIE STEVENS TANIA STUBBS DANIEL SULLIVAN DARIN TARMEY TAYLOR CORRY TERRAZAS MONICA THOMAS AHMAD TRAVAGLIO-WILLIAMS CHER UROW BARBARA URTECHO VASTA WALTERS IRISH WALTON WASHINGTON WILLIS WEEKES KATHLEEN WENTWORTH JEAN WEST COKENYA WESTBERRY ANSON WHITE DEON WILLIAMS BRYSHAWN WILLIAMS HANEY WILLIAMSON WRITER CYRUS ZAPATA MARLON Active Retiree Printed Date: $2,375.58 $0.00 $2,375.58 $178,642.62 $52,441.51 $231,084.13 $785.10 $0.00 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