HomeMy WebLinkAboutInv# 2024-00000738 - Fidelity Security Life Insurance Company - 08/28/2024 (3)eveEyeMed 4000 LUXOTTICA PL MASON OH 45040-8114
Forwarding Service Requested
THE CITY OF DAN1A BEACH COBRA LINDA GONZALE I 00 W. DAN1A BEACH BLVD. DANIA BEACH FL 33004
BILLING PERIOD: July, 2024
FULL MONTH
COVERAGE TIER
Benefit Level 1
Employee + Family
1,243 202-40626B05 J4C2 JlOO 38195 J4C2 [1,243) 3 of6
[DM-BS]
SUMMARY INVOICE FOR: The City of Dania Beach COBRA
GROUP ID: 5000544
SUBGROUP ID: 1001
INVOICE NUMBER: 166337400
COUNT RATE TOTAL
$12.24 $12.24
FULL MONTH TOTAL $12.24
CURRENT BILLING PERIOD TOTAL
PAYMENT IS DUE IN FULL UPON RECEIPT eve THE INVOICE CALCULATION IS BASED ON MEMBERSHIP AS OF 06/20/24 PLEASE DETACH AND RETURN
THE CITY OF DANIA BEACH COBRA LINDA GONZALE 100 W. DANIA BEACH BLVD. DANIA BEACH FL 33004
Remit To: FIDELITY SECURITY LIFE INSURANCE CO.PO BOX 632530 CINCINNATI OH 45263-2530
GROUP ID: 5000544
SUBGROUP ID: 1001
INVOICE NUMBER: 166337400
TOTAL INVOICE AMOUNT DUE: $12.24
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