HomeMy WebLinkAboutInv# 2023-00000608 - FLORIDA MUNICIPAL INSURANCE TRUST - 07/31/2023PREMIUMS ADJUSTMENTS TOTAL
Medical Plan 2 Employee + 1 32 $49,538.56 $0.00 $49,538.56
Medical Plan 2 Employee + Family 46 $109,276.68 $0.00 $109,276.68
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 7 $4,748.45 $0.00 $4,748.45
$0.00 $0.00
$231,082.29 $0.00 $231,082.29 July Due
:$458,220.54
:-$231,084.13 May Pymt
:$231,082.29
:$0.00
:$458,218.70
$227,136.41 June Paid
Refund for Retirees JOSEPH BERTUCCIO & DONALD HANSEN are on the August invoice and will include the July. MS
TERMED W/ADJ
DANIA BEACH Due Date: 07-01-2023
FMIT # FH0129
SUMMARY BILLING PAGE
COVERAGE
TOTAL DUE
Gen Date: 06-20-2023
BALANCE FORWARD
PAYMENTS
CURRENT PREMIUMS
ADJUSTMENTS 7/28/23
Check Date.Calendar July 2023 FMIT NW Payroll report
Batch Status Posted A penny more in payroll
Deduction Codes (Multiple Items)KNUDSON THEODOREA Medical Plan 5 Employee Onl $678.35
Benefit Code (Multiple Items)Added this calc MCDOWELL KEITH A Medical Plan 5 Employee Onl $678.35
FMIT Invoice OZAYDIN DINCER A Medical Plan 5 Employee Onl $678.35
Row Labels Deduction Net Benefit Net STATCOVERAGE TPLAN NAMTIER PREMIUM ADJUSTMEN TOTAL SPEAR MITZIE A Medical Plan 5 Employee Onl $678.35
ACOSTA, RAFAEL 380.10 1,995.48 2,375.58$ TRUE ACOSTA RAFAEL A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00 WILLIAMS BRYSHAWNA Medical Plan 5 Employee Onl 678.35
ADAMS, LORI 125.62 659.48 785.10$ TRUE ADAMS LORI A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
ALI, RICKY A 380.10 1,995.48 2,375.58$ TRUE ALI RICKY A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
ALPHONSE, LOU 247.70 1,300.38 1,548.08$ TRUE ALPHONSE LOU A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00 Term
ANAYA, ALEXANDRA 125.62 659.48 785.10$ TRUE ANAYA ALEXANDRA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
AZCANO, ALEJANDRO 125.62 659.48 785.10$ TRUE AZCANO ALEJANDRO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00 WEEKES KATHLEEN A Medical Plan 2 Employee + 1 $1,548.08
BALDIE, TOMMY R 380.10 1,995.48 2,375.58$ TRUE BALDIE TOMMY A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00 Retiree - refund will hit next month
BATISTA, CLAUDIA 380.10 1,995.48 2,375.58$ TRUE BATISTA CLAUDIA A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
BORDY, KATIA 125.62 659.48 785.10$ TRUE BORDY KATIA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
BOUTSIS, EVE 125.62 659.48 785.10$ TRUE BOUTSIS EVE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
BROWN, ERIC 380.10 1,995.48 2,375.58$ TRUE BROWN ERIC A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
BROWN, LOUIS 125.62 659.48 785.10$ TRUE BROWN LOUIS A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
BROWN, RODRICK 247.70 1,300.38 1,548.08$ TRUE BROWN RODRICK A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
BROWNE, JOHNATHAN 247.70 1,300.38 1,548.08$ TRUE BROWNE JOHNATHAN A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
CANGIALOSI, JOSEPH S 125.62 659.48 785.10$ TRUE CANGIALOSI JOSEPH A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
CHEN, MICHAEL K 247.70 1,300.38 1,548.08$ TRUE CHEN MICHAEL A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
COLLINS, ROGER J JR 125.62 659.48 785.10$ TRUE COLLINS ROGER A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
COOK, RONALD L 380.10 1,995.48 2,375.58$ TRUE COOK RONALD A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
COSTA, NATHAN J 380.10 1,995.48 2,375.58$ TRUE COSTA NATHAN A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
CRAWFORD, RUPERT 380.10 1,995.48 2,375.58$ TRUE CRAWFORD RUPERT A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
CROSS, JERRYLYN 125.62 659.48 785.10$ TRUE CROSS JERRYLYN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
DAMIS, WINDY 380.10 1,995.48 2,375.58$ TRUE DAMIS WINDY A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
DAVILA, EDDA K 380.10 1,995.48 2,375.58$ TRUE DAVILA EDDA A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
DAVIS, JOYCE L 125.62 659.48 785.10$ TRUE DAVIS JOYCE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
DE JESUS, GABRIEL 247.70 1,300.38 1,548.08$ TRUE DE JESUS GABRIEL A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
DIPAOLO, FRANK L 380.10 1,995.48 2,375.58$ TRUE DIPAOLO FRANK A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
DOMINGUEZ, MARIA M 247.70 1,300.38 1,548.08$ TRUE DOMINGUEZ MARIA A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
DONNELLY, COLIN E 380.10 1,995.48 2,375.58$ TRUE DONNELLY COLIN A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
DOTSON, RICKEY 125.62 659.48 785.10$ TRUE DOTSON RICKEY A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
DRUMMOND, TAMARA 125.62 659.48 785.10$ TRUE DRUMMOND TAMARA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
Edge, Charles J 125.62 659.48 785.10$ TRUE EDGE CHARLES A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
EKLE, ROBERT 125.62 659.48 785.10$ TRUE EKLE ROBERT A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
FRANCO, JOSHUA 125.62 659.48 785.10$ TRUE FRANCO JOSHUA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
GAINES, TANEISHA 125.62 659.48 785.10$ TRUE GAINES TANEISHA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
GARDNER, KALA F 125.62 659.48 785.10$ TRUE GARDNER KALA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
GRANT, MITCHELL V 247.70 1,300.38 1,548.08$ TRUE GRANT MITCHELL A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
GREENE, DARREN D 380.10 1,995.48 2,375.58$ TRUE GREENE DARREN A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
GUZMAN, YEIMY 380.10 1,995.48 2,375.58$ TRUE GUZMAN YEIMY A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
HARRIS, WILLIAM G 247.70 1,300.38 1,548.08$ TRUE HARRIS WILLIAM A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
Henley, Mokieta L 125.62 659.48 785.10$ TRUE HENLEY MOKIETA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
HIRSCH, STACY 247.70 1,300.38 1,548.08$ TRUE HIRSCH STACY A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
HOGGINS, ERNEST 247.70 1,300.38 1,548.08$ TRUE HOGGINS ERNEST A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
HUCK, MICHAEL 380.10 1,995.48 2,375.58$ TRUE HUCK MICHAEL A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
HUGHES, ANASTACIA R 380.10 1,995.48 2,375.58$ TRUE HUGHES ANASTACIA A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
ICENHOUR, RACHEL 125.62 659.48 785.10$ TRUE ICENHOUR RACHEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
IFEDI, ANTHONY 125.62 659.48 785.10$ TRUE IFEDI ANTHONY A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
IGLESIAS GUTIERREZ, CLAUDIO 125.62 659.48 785.10$ TRUE IGLESIAS GUTIERREZ CLAUDIO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
JACKSON, JOHNATHAN 125.62 659.48 785.10$ TRUE JACKSON JOHNATHAN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
JAMES, TAMARA 247.70 1,300.38 1,548.08$ TRUE JAMES TAMARA A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
JAMES, TAMMIE D 247.70 1,300.38 1,548.08$ TRUE JAMES TAMMIE A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
JELASO, MEGAN 380.10 1,995.48 2,375.58$ TRUE JELASO MEGAN A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
JOHNSON JR, KENNITH 247.70 1,300.38 1,548.08$ TRUE JOHNSON JR KENNITH A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
JOHNSON, ANTOINE 125.62 659.48 785.10$ TRUE JOHNSON ANTOINE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
JOHNSON, BRANDON 125.62 659.48 785.10$ TRUE JOHNSON BRANDON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
JOLLY, CORY 380.10 1,995.48 2,375.58$ TRUE JOLLY CORY A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
JOSEPH, PATRICK 125.62 659.48 785.10$ TRUE JOSEPH PATRICK A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
KALLICHARAN, CARL 125.62 659.48 785.10$ TRUE KALLICHARAN CARL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
KNUDSON, THEODORE 108.54 569.82 678.36$ FALSE KNUDSON THEODORE A Medical Plan 5 Employee Only $678.35 $0.00 $678.35 FALSE -$0.01 penny
LAJOIE, CORINNE A 247.70 1,300.38 1,548.08$ TRUE LAJOIE CORINNE A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
LARIOS IBARGUEN, IBEL E 125.62 659.48 785.10$ TRUE LARIOS IBARGUEN IBEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
LAWSON, RACHELLE 380.10 1,995.48 2,375.58$ TRUE LAWSON RACHELLE A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
LEWELLEN, LORI B 247.70 1,300.38 1,548.08$ TRUE LEWELLEN LORI A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
LIMA, MARILANE R 125.62 659.48 785.10$ TRUE LIMA MARILANE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
LOBO, YAMIL 380.10 1,995.48 2,375.58$ TRUE LOBO YAMIL A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
LOTTIER, CHRISTINE A 247.70 1,300.38 1,548.08$ TRUE LOTTIER CHRISTINE A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
MARTIN, RALPH 380.10 1,995.48 2,375.58$ TRUE MARTIN RALPH A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
MARTINEZ, GABRIEL 125.62 659.48 785.10$ TRUE MARTINEZ GABRIEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
McDonald, Marvin JR 380.10 1,995.48 2,375.58$ TRUE MCDONALD MARVIN A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
MCDOWELL, KEITH 108.54 569.82 678.36$ FALSE MCDOWELL KEITH A Medical Plan 5 Employee Only $678.35 $0.00 $678.35 FALSE -$0.01 penny
MCFARLANE, DARRYL 125.62 659.48 785.10$ TRUE MCFARLANE DARRYL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
MCHELLON, DONIAL 380.10 1,995.48 2,375.58$ TRUE MCHELLON DONIAL A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
MCLAREN, KRISTEN M 380.10 1,995.48 2,375.58$ TRUE MCLAREN KRISTEN A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
MCNEAL, GREGORY 380.10 1,995.48 2,375.58$ TRUE MCNEAL GREGORY A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
MERCADO, KARLA 380.10 1,995.48 2,375.58$ TRUE MERCADO KARLA A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
Mierez, Ann 125.62 659.48 785.10$ TRUE MIEREZ ANN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
MIRANDA, SHANESA 125.62 659.48 785.10$ TRUE MIRANDA SHANESA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
NORENA, ELEANOR 380.10 1,995.48 2,375.58$ TRUE NORENA ELEANOR A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
OZAYDIN, DINCER A 108.54 569.82 678.36$ FALSE OZAYDIN DINCER A Medical Plan 5 Employee Only $678.35 $0.00 $678.35 FALSE -$0.01 penny
PECORARO, SHERRY 380.10 1,995.48 2,375.58$ TRUE PECORARO SHERRY A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
PEGUERO, ULYSSES 125.62 659.48 785.10$ TRUE PEGUERO ULYSSES A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
PEIRCE, LOGAN 125.62 659.48 785.10$ TRUE PEIRCE LOGAN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
Penate Roque, Delmis 380.10 1,995.48 2,375.58$ TRUE PENATE ROQUE DELMIS A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
PEREZ, FRANK 247.70 1,300.38 1,548.08$ TRUE PEREZ FRANK A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
PERRY, LEONARD H 125.62 659.48 785.10$ TRUE PERRY LEONARD A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
PETERSON, TERRY 247.70 1,300.38 1,548.08$ TRUE PETERSON TERRY A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
POLLARD, ALBERLEAN S 380.10 1,995.48 2,375.58$ TRUE POLLARD ALBERLEAN A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
QUINTERO, JOHN 125.62 659.48 785.10$ TRUE QUINTERO JOHN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
REYES, EDDIE 125.62 659.48 785.10$ TRUE REYES EDDIE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
Riera, Elora R 108.54 569.82 678.36$ FALSE RIERA ELORA A Medical Plan 5 Employee Only $678.35 $0.00 $678.35 FALSE -$0.01 penny
RODRIGUEZ, FERNANDO 125.62 659.48 785.10$ TRUE RODRIGUEZ FERNANDO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
RODRIGUEZ, HAROLD 247.70 1,300.38 1,548.08$ TRUE RODRIGUEZ HAROLD A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
RODRIGUEZ, MICHAEL S 125.62 659.48 785.10$ TRUE RODRIGUEZ MICHAEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
RODRIGUEZ, RICHARD 380.10 1,995.48 2,375.58$ TRUE RODRIGUEZ RICHARD A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
EMPLOYEE NAME
Ryan, Archibald J IV 380.10 1,995.48 2,375.58$ TRUE RYAN ARCHIBALD A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
SABINO, DEBORAH 247.70 1,300.38 1,548.08$ TRUE SABINO DEBORAH A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
SALGADO, JOSE F 380.10 1,995.48 2,375.58$ TRUE SALGADO JOSE A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
SALVINO, MARCO SR 125.62 659.48 785.10$ TRUE SALVINO MARCO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
SANTANA TORRES, JULIO M JR 125.62 659.48 785.10$ TRUE SANTANA JULIO A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
SAUNDERS, JANICE L 247.70 1,300.38 1,548.08$ TRUE SAUNDERS JANICE A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
SEGAL, ADAM 380.10 1,995.48 2,375.58$ TRUE SEGAL ADAM A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
Shahryar, Michelle M 247.70 1,300.38 1,548.08$ TRUE SHAHRYAR MICHELLE A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
SHELEY, CHERIE 125.62 659.48 785.10$ TRUE SHELEY CHERIE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
SINGH, KEVIN N 125.62 659.48 785.10$ TRUE SINGH KEVIN A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
SINGH, MAXINE A 125.62 659.48 785.10$ TRUE SINGH MAXINE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
SPEAR, MITZIE P 108.54 569.82 678.36$ FALSE SPEAR MITZIE A Medical Plan 5 Employee Only $678.35 $0.00 $678.35 FALSE -$0.01 penny
Spencer, Angela 125.62 659.48 785.10$ TRUE SPENCER ANGELA A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
SPENCER, WILLIE 125.62 659.48 785.10$ TRUE SPENCER WILLIE A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
STEVENS, TANIA A 247.70 1,300.38 1,548.08$ TRUE STEVENS TANIA A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
TAYLOR, CORRY G 247.70 1,300.38 1,548.08$ TRUE TAYLOR CORRY A Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE $0.00
TERRAZAS, MONICA M 380.10 1,995.48 2,375.58$ TRUE TERRAZAS MONICA A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
THOMAS, AHMAD 380.10 1,995.48 2,375.58$ TRUE THOMAS AHMAD A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
UROW, BARBARA 380.10 1,995.48 2,375.58$ TRUE UROW BARBARA A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
VASTA, MICHAEL J 125.62 659.48 785.10$ TRUE VASTA MICHAEL A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
WALTON, ERIC J 380.10 1,995.48 2,375.58$ TRUE WALTON ERIC A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
WASHINGTON JR, WILLIS B 380.10 1,995.48 2,375.58$ TRUE WASHINGTON WILLIS A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $0.00
WEST, COKENYA D 380.10 1,995.48 2,375.58$ #REF!WEST COKENYA A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE $1,590.48
WESTBERRY, ANSON J 125.62 659.48 785.10$ FALSE WESTBERRY ANSON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
WHITE, DEON T 125.62 659.48 785.10$ TRUE WHITE DEON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
Williams Haney, Charles E JR 125.62 659.48 785.10$ TRUE WILLIAMS BRYSHAWN A Medical Plan 5 Employee Only $678.35 $0.00 $678.35 FALSE -$0.01
WILLIAMS, BRYSHAWN 108.54 569.82 678.36$ FALSE WILLIAMS DARIUS A Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 FALSE $0.00 penny
WILLIAMS, DARIUS 380.10 1,995.48 2,375.58$ TRUE WILLIAMS HANEY CHARLES A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 FALSE $0.00
WRITER, CYRUS 125.62 659.48 785.10$ TRUE WRITER CYRUS A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE $0.00
ZAPATA, MARLON 125.62 659.48 785.10$ TRUE ZAPATA MARLON A Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE
Grand Total 28,712.38 150,735.68 179,448.06$
-$
STATUS COVERAGE PLAN NAM TIER PREMIUM ADJUSTME TOTAL First Name Middle Name Last Name
ANSBRO NOAH R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Noah Blue Ansbro
BAKER ERIC R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE ERIC J BAKER
BERTUCCIO JOSEPH R Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 FALSE 7/1/2023 refunded on August invoice
BROWN KENNETH R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Kenneth Sean Brown
CARUSO BRUCE R Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE BRUCE CARUSO
CHANDLER CHRISTOPHER R Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE Christopher Chandler
DARA MICHAEL R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Michael Frank Dara
GARCIA GONZALO R Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE GONZALO GARCIA
GONZAGA LIVANIA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Livania Gonzaga
HANSEN DONALD R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 FALSE 7/1/2023 refunded on August invoice
HENG PETER R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Peter Heng
HUSOSKY JOSEPH R Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE JOSEPH A HUSOSKY
JOHNSON ANTHONY R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE ANTHONY JOHNSON
JOHNSON STANLEY R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE STANLEY JOHNSON
KENON FLOYD R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE FLOYD KENON
LAVINA ARMENIO R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Armenio Lavina
LEXA JOHN R Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE JOHN LEXA
LIEM BRUCE R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Bruce Liem
LORBER RICHARD R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Richard Glenn Lorber
MACE ANGELINA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Angelina Deloris Mace
MARIANI JENNIFER R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Jennifer E Mariani
MCDONALD MARY R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE MARY L MCDONALD
MUSTELIER JR ENRIQUE R Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE ENRIQUE MUSTELIER JR
NEAL TODD R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Todd Michael Neal
PATTERSON DIANNA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE DIANNA L PATTERSON
PELLECER SERGIO R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE SERGIO PELLECER
PHIPPS BRIAN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Brian Phipps
RIVIERE JOSEPH R Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE JOSEPH A RIVIERE
RODRIGUEZ JOSE R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Jose Rodriguez
ROSE MARY R Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE Mary Rose
ROSS LUISA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Luisa P Ross
RUDBECK BENJAMIN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Benjamin Clinton Rudbeck
RUETH PATRICIA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Patricia Jean Rueth
SATTERFIELD NICKI R Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE NICKI J SATTERFIELD
SIEB RICHARD R Medical Plan 5 Employee Only $678.35 $0.00 $678.35 TRUE Richard Sieb
SLADE CURTIS R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE CURTIS SLADE
SMITH MICHAEL R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE MICHAEL W SMITH
SNELL ARNOLD R Medical Plan 2 Employee + Family $2,375.58 $0.00 $2,375.58 TRUE Arnold J Snell
SOMERS PATRICIA R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Patricia Somers
STUBBS DANIEL R Medical Plan 2 Employee + 1 $1,548.08 $0.00 $1,548.08 TRUE DANIEL STUBBS
SULLIVAN DARIN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Darin Sullivan
TARMEY LORI R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Lori Ann Tarmey
TRAVAGLIO-WILLIAMS CHER R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Cher Travaglio-Williams
URTECHO JOSE R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE JOSE B URTECHO
WALTERS IRISH R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE Irish Gean Walters
WENTWORTH JEAN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE JEAN WENTWORTH
WILLIAMSON JOHN R Medical Plan 2 Employee Only $785.10 $0.00 $785.10 TRUE John E Williamson
$50,086.21 $0.00 $50,086.21
EMPLOYEE NAME
Invoice Retiree report