HomeMy WebLinkAboutInv# 2024-00000637 - AFLAC - 07/30/2024Account Name:
Address:
Date Prepared:
Billing Frequency:
Aflac
PO Box 673025, Dallas TX 75267-3025
Aflac .com
COPY -Or iginal Inv oice
~ paying by paper check, please reconcile online and send },Our check with the printed payme nt coupon to the address listed above.
CITY OF DANIA
Attn Linda Gonzalez-Ext 3608
100 W Dania Beach Blvd
DAN IA, FL 33004-3643
7/15/2024
MONTHLY
Invoice Copy
7/28/2024
Invoice Number:
Account Number:
Premium Due Dat e:
Amou nt Billed :
Amount Remitting :
Billing Period:
Number of Deduct ions:
Deduction Frequency:
Billing Mode:
743134
FWW12
8/1/2024
$2,636.76
$2,636.76
July
2
24
MONTHLY
" Highlighted lines indicate that the premium amount being remitted was adjus ted and/or a Change Request was submitted for the employee.
The premium amount billed for some policies may not reflect the number of deductions indicated above if the
policies were issued during the billing period. If paying by paper check, please reconcile on line and send
your check with the printed payment coupon to the address listed above.
Policy Polley CT Dept. Employee/ Name RM Premium Employee Adjusted Adjusted CR Type Member# Due Sub-Total Premium Sub-Total
82865120 HOSP I 0000000549 BROWN, LOUIS $27.44 $27.44
B2865121 SPEVNT I 0000000549 BROWN, LOUIS $31.86 $31.86
P0B8K0A2 ACC I 0000000549 BROWN, LOUIS $22.36 $22.36
P0B8K0D1 CANCER I 0000000549 BROWN, LOUIS $26.90 $108.56 $26.90 $108.56
P0R3Y2D7 HOSP I 0000001641 CROSS, JERRYL YN $57.60 $57.60 $57.60 $57.60
P0R265B6 ACC F 0000001806 DAMIS, WINDY $59.02 $59.02 $59.02 $59.02
P0L9D6C2 ACC s 0000001878 DEMASSIS, TAMARAC S35.76 $35,76
P0L9D6C4 HOSP s 0000001878 DEMASSIS, TAMARAC $77.62 $113.38 $77.62 $113.38
P0V6J5F0 CANCER F DIPAOLO, FRANK $91.36 $91.36 $91.36 $91.36
P0B898A4 STD I DIPAOLO, FRANK L $61.50 $61.50
P0B898A5 HOSP F DIPAOLO, FRANKL $85.94 $147.44 $85.94 $147.44
P0B8K354 ACC s 0000001670 GARDNER, KALA $35.76 $35.76
P0B8K362 HOSP s 0000001670 GARDNER, KALA $37.58 $73.34 $37.58 $73.34
P0G5T8F3 ACC F 0000001239 GREENE, DARREN $46.68 $46.68 $46.68 $46.68
P0Z7R9L8 CANCER F HUCK, MICHAEL $108.84 $108.84 $108.84 $108.84
B3058189 ACC F 0000001700 HUCK, MICHAEL $46.68 $46.68 $46.68 $46.68
P0L9D6C1 ACC s 0000001820 ICENHOUR, RACHEL N $35.76 $35.76 $35.76 $35.76
P0V621U3 ACC s 0000001885 JAMES, TAMARA E $43 .16 $43.16 $43.16 $43.16
P0B8K0J8 CANCER F 0000001314 JAMES, TAMMIE D $54.00 $54.00
P0B8K0K5 HOSP F 0000001314 JAMES, TAMMIE D $71.64 $71 .64
P0G5T8E4 ACC F 0000001314 JAMES, TAMM IE D $46.68 $172.32 $46.68 $172.32
P0B8K0A6 ACC F 0000000947 MCHELLON, DONIAL $46.68 $46.68
P0B8K0D2 CANCER F 0000000947 MCHELLON, DONIAL $45.50 $92.18 $45.50 $92.18
P0J8H1S3 ACC F 0000001797 PECORARO, SHERRY A $46.68 $46.68
• continued on next page •
LEGEND
COVERAGE TYPE (CT\ REMARKS (RM\ CHANGE REQUEST (CR\
I = Individual CV = Pending Convers ion A= Add person to policy H = Name Change 0 = O ther
F = Family PA = Policy is Paid Ahead C = Cancel Coverage I = Delete person from policy R = Retired
S = Single-Parent Family PC = Policy is Pending Conversion D=Deceased L = Non-Family Medical Leave T = No longer employed here
P = Primary-Spouse and is Paid Ahead E = Unknown Insured-Remove M = Missed Deduction W = Transfer to another account
F = Family Medical Leave Y = Military Leave
Page1of2
Aflac
PO Box 6730 25, Dallas T X 75267-3025
1-800-99-AFLAC (1-800 -992-3522)
Af lac.com COPY • Original I nvoic e
If paying by paper check, please reconcile online and send your check with the printed payment coupon l o the address listed above.
" Highlighted l ines indicate that the premium amount being remitted was adj usted and/or a Change Request was submitted for the employee.
The premium amount billed for some policies may not reflect the number of deductions indicated above if the
policies were issued during the billing period. If paying by paper check, please reconcile online and send
your check with the printed payment coupon to the address listed above .
Polley Polley CT Dept. Employee/ Name RM Premium Employee Adjusted Adjusted CR Type Member# Due Sub-Total Premium Sub-Total
P0L9D6C3 CANCER I 0000001797 PECORARO,SHERRYA S62.54 $109.22 $62.54 $109.22
P0B8K0A7 CANCER F 0000001750 PEREZ, FRANK $45.50 $45.50 $45.50 $45.50
P0G5T8F1 ACC p REYES , EDDIE $38.22 $38.22
P0Y443K1 HOSP p REYES, EDDIE $133.52 $171.74 $133.52 $171 .74
P0X152H4 ACC I RODRIGUEZ, HAROLD $24.32 $24.32
P0X152H5 HOSP I RODRIGU EZ, HAROLD $75.66 $99.98 $75.66 $99.98
P1B269A5 ACC I RODRIGUEZ, MICHAEL $24.32 $24.32
P1B26945 CANCER I RODRIGUEZ, MICHAEL $60.94 $85.26 $60.94 $85.26
P0T3Y4C9 HOSP I 0000001680 RODRIGUEZ, MICHAEL $47.32 $47.32 $47.32 $47.32
P0B8K352 ACC F 0000001682 RODRIGUEZ, RICHARD $59.02 $59.02
P0B8K358 CANCER F 0000001682 RODRIGUEZ, RICHARD $48.80 $107.82 $48.80 $107.82
P0G5T8E8 ACC I 0000001168 SALGADO, JOSE $22.36 $22.36 $22.36 S22.36
P0B8K0J0 ACC p 0000001321 SAUNDERS, JANICE $33.28 $33.28
P0B8K0K3 HOSP p 0000001321 SAUNDERS, JANICE $84.38 $117.66 $84.38 $117.66
P0V621U2 ACC I 0000001879 SHELEY, CHERIE A $24.32 $24.32 $24.32 S24.32
P1C410P5 ACC I SMITH, ROY $24.32 524.32 $24.32 $24.32
P0V621L3 HOSP I 0000001343 STEVENS, TANIA A $64.48 $64.48
P0V621U1 ACC I 0000001343 STEVENS, TANIA A $24.32 $88.80 $24.32 $88.80
P0B8K0A4 ACC F 0000000946 THOMAS, AHMAD $46.68 $46.68
P0B8K099 HOSP F 0000000946 THOMAS, AHMAD $63.18 $109.86 $63.18 $109.86
P0J8H1S6 ACC I 0000001676 VASTA, MICHAEL $22.36 $22.36 $22.36 $22.36
P0H8A2F9 STD I WAREN, CASSANDRA S76.06 $76.06 $76.06 $76.06
P0J8H1T1 ACC s 0000001173 WEST, COKENYA $35.76 $35.76 $35.76 $35.76
P0V621L4 ACC I 0000001828 WESTBERRY, ANSON J $24.32 $24.32 $24.32 $24.32
P0B8K355 ACC F 0000001403 WHITE, DEON $46.68 $46.68 $46.68 $46.68
P0Y4A937 ACC p WILLIAMS, DARIUS $38.22 $38.22
P0Y4A938 HOSP F WILLIAMS, DARIUS $120.52 $158.74 $120.52 $158.74
P0B8K0A3 ACC I 0000001671 ZAPATA, MARLON $22.36 $22.36 $22.36 $22.36
Total Amount Billed: $2,636.76 Amt Due $2,636.76 ...
LEGEND
COVERAGE TYPE (CT) REMARKS /RM) CHANGE REQUEST (CR)
I = Individual CV = Pending Conversion A= Add person to policy H = Name Change 0 = Other
F = Family PA = Policy is Paid Ahead C= Cancel Coverage I = Delete person from policy R = Retired
S = Single-Parent Family PC = Policy is Pending Conversion D=Deceased L = Non-Family Medical Leave T = No longer employed here
P = Primary-Spouse and is Paid Ahead E = Unknown Insured-Remove M = Missed Deduction W = Transfer to another account
F = Family Medical Leave Y = Military Leave
Page 2 of2
Che ck Date.Calendar
July 2024
New Worl d Info
Pay Batch A ll
Batch Status Posted -
Deduction Net Deduction Cod Deduction Code
Groupl Other Grand Total
Employee AFLAC 2 AFLAC 3 AFLAC4 AFLAC 5 AFLAC l
-
BR OWN, LOUIS 31.86 27.44 26 .90 22.36 108.56
CROSS, JERRYLYN 57.60 57.60
DAMIS, W INDY 59.02 59.02
DEM ASSIS, TAMARA 77.62 35.76 113.38
DI PAOLO, FRA N K L 85.94 91.36 61.50 238.80
GARDNER, KALAF 37.58 35.76 73.34
GREEN E, D ARREN D 46.68 46.68
HUCK, MICH AEL 108.84 4 6.68 155.52
ICENHOUR, RACHEL 35.76 35.76
JA MES, TA M ARA 43.16 43.16
JAMES, TA M M IE D 71.64 5 4.00 4 6.68 172.32
M CHE LLON, DONIAL 4 5.50 4 6.68 92.18
PECORARO, SH ERRY 62.54 4 6.68 109.22
PEREZ, FRAN K 4 5.50 45.50
REYES, EDDI E 133.52 38.22 171.74
RODRIGU EZ, H A RO LD 75.66 24.32 99.98
RODRIGU EZ, MICHAELS 47.32 60.94 24.32 132.58
RODRIGUEZ, RICH A RD 48.80 59.02 107.82
SALGADO, JOSE F 22.36 22.36
SA UNDERS, JA N ICE L 84.38 33.28 117.66
SHELEY, CH ERIE 24.32 24.32
Smith, Roy 24.30 24.30
ST EVE NS, TANIA A 64.48 24.32 88.80
T HOMAS, A HMA D 63.18 46.68 109.86
VASTA, M ICHAELJ 22.36 22.36
W ARE N, CA SSAN DRA 76.06 76.06
W EST, COKENYA D 35.76 35.76
WESTB ER RY, ANSON J 24.32 24.32
W H ITE, DEON T 4 6.68 46.68
W ILLIAMS, DARI US 120.52 38.22 158.74
ZAP ATA , M ARLON 22.36 22.36 --
Grand Total 31.86 946.88 544.3 8 137.56 976.06 2,636.74
($0.02)
Can exp ort i nvoice t o an Excel spreadsheet to p u ll into this report
Aflac Invoice
•Frank D & M i ke Huck -copy in w only o n e line -ad d the 2 t ot als together
Name Part# De Policy# Policy Cov. Po licy Premium
pt. Type Type Premium Subtotal
BROWN LOUIS 0000000549 P0B8K0D 1 CANCER I $26.90 $108.56
CROSS JERRYL YN 0000001641 P0R3Y2D7 HOSP I $57.60 $57.60
DAMIS WINDY 0000001806 P0R26586 ACC F $59.02 $59.02
DEMASSIS TAMARAC 0000001878 P0L9D6C4 HOSP s $77.62 $113.38
DIPAOLO FRANKL P0B898A5 HOSP F $85.94 $238.80
GARDNER KALA 0000001670 P0B8K362 HOSP s $37.58 $73.34
GREENE DARREN 0000001239 P0G5T8F3 ACC F $46.68 $46 .68
HUCK MICHAEL 0000001700 83058189 ACC F $46.68 $155.52
ICEN HOUR RACHEL N 0000001820 P0L9D6C1 ACC s $35.76 $35.76
JAMES TAMARA E 0000001885 P0V621U3 ACC s $43.16 $43.16
JAMES TA MMIE D 000000131 4 P0G5T 8E4 ACC F $46.68 $172.32
MCHELLON DO NIAL 0000000947 P088K0D2 CANCER F $45.50 $92.18
PECORARO SHERRY A 0000001797 P0L9D6C3 CANCER I $62.54 $109.22
PEREZ FRANK 0000001750 P0B8K0A7 CANCER F $45 .50 $45.50
REYES EDD IE P0Y443K1 HOSP p $133.52 $171.74
RODRIGUEZ HAROLD P0X152H5 HOSP i $75.66 $99.98
RODRIGUEZ MICHAEL 0000001680 P0T3Y4C9 HOSP I $47.32 $132.58
RODRIGUEZ RICHARD 0000001682 P0B8K358 CANCER F $48.80 $107.82
SALGADO JOSE 0000001168 P0G5T8E8 ACC I $22.38 $22.36
SAUNDERS JANICE 0000001321 P0B8K0K3 HOSP p $84.38 $117.66
SHELEY CHERIE A 0000001879 P0V621U2 ACC l $24.32 $24.32
Smith, Roy P1C410P5 ACC l $24.32 $24.32
ST EVENS TANIA A 0000001343 P0V621U1 ACC l $24.32 $88.80
THOMAS AHMAD 0000000946 P0B8K099 HOSP F $63.18 $109.86
VASTA M ICHAEL 0000001676 P0J8H1S6 ACC l $22.36 $22.36
WAREN CASSANDRA P0H8A2F9 STD l $76.06 $76.06
WEST COKENYA 0000001173 P0J8H1T1 ACC s $35.76 $35.76
WESTBERRY ANSON J 0000001828 P0V621L4 ACC l $24.32 $24.32
WHITE DEON 0000001403 P0B8K355 ACC F $46.68 $46.68
WILLIAMS OARIUS P0Y4A938 HOSP p $120.52 $158.74
ZAPATA MARLON 0000001671 P0B8K0A3 ACC l $22.36 $22.36
$2636.76
0.00
0 .00
0.00
0 .00
0 .00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
-0.02
-64.50
-21.06
87.50
-53.70
40.30
11.44
-22.36
-112.06
136.38