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Home My WebLink AboutInv# 2024-00001151 - AFLAC - 11/21/2024 (2)Affac, Aflac PO Box 673025, Dallas T% 75267.3025 Aflac.com COPY - Original Invoice If paying by paper check, please reconcile online and send your check with the printed payment coupon to the address listed above. Invoice Copy Invoice Number: 080899 11/152024 Account Number: FWW12 Account Name: CITY OF DANIA Premium Due Date: 12/12024 Address: Attn Linda Gonzalez-Ert 3608 Amount Billed: $2,659.62 100 W Dania Beach Blvd Amount Remitting: $2.659.62 DANIA, FL 33004-3643 Billing Period: November Number of Deductions: 2 Deduction Frequency: 24 Billing Mode: MONTHLY Date Prepared: 11/14/2024 Billing Frequency: MONTHLY Highlighted lines Indicate that the premium amount being remitted was adjusted 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. Policy Type CT Dept. EmpMemiber# Name RM Premium Employee usted Adjusted CR Sub -Total um Sub -Total PIC894SI CANCER I BACAROSSI, BIANCAMARIA $60.94 $60.94 $60A4 $60.94 P0R3Y2D7 HOSP 1 0000001641 CROSS, JERRYLYN $57.60 $57.60 $57.60 $57.60 POR26506 ACC F ON0001806 DAMIS, WINDY $59.02 $59.02 $59.02 stiam P0L9D6C2 ACC S 0000001978 DEMASSIS, TAMARA C $35.76 $35.76 POL9D&C4 HOSP S OM001878 DEMASSIS, TAMARA C $77.62 $113.38 $77.62 $113.38 P0V6J5F0 CANCER F DIPAOLO, FRANK $91.36 $91.36 $91.36 $91.S6 POB89844 STD I DIPAOLO, FRANK $61.50 $61.60 POB89W HOSP F DIPAOLO, FRANK L $85.94 $147.44 $85.94 $147.44 P0138051 ACC S MNOD1670 GARDNER, KALA $35.76 $35.76 POBSK362 HOSP B MODOO1670 GARDNER. KALA $37.58 $73.34 $37.58 $73.34 P0GST8F3 ACC F 00W001239 GREENE, DARREN S46.69 $46.68 $46.68 WAS P0271391-8 CANCER F HUCK, MICHAEL $108.84 $108.84 $108.84 $1o8.84 B30581S9 ACC F 0000001700 HUCK, MICHAEL $46.68 $46.68 $46.68 $46.68 P0L9D&C 1 ACC S 0000001820 ICENHOUR, RACHEL N $35.76 $35.76 $35.76 $35.76 P0V621U3 ACC S 0000001885 JAMES, TAMARAE $43.16 WAS $43.16 $43.16 POB8KOJB CANCER F 0000001314 JAMES, TAMMIED $54.00 $54.00 1301SWOK5 HOSP F OM0001314 JAMES, TAMMIED $71.64 $71.64 P035TBE4 ACC F OM001314 JAMES, TAMMIE0 $46.68 $172.32 $46.68 $172.32 PIC695BB HOSP I ONN01M JOLLY, CORY $68.52 $68.52 P1C6%B9 ACC I OW0001890 JOLLY, CORY $24.32 $92.84 $24.32 $92.84 P0B8KOA6 ACC F ONNO0947 MCHELLON, DOtIlAL $46.68 $46.68 P008K0D2 CANCER F 000(1000947 MCHELLON, DONIAL $45.50 $W.18 $45.50 $92.18 P0J8H1S3 ACC F 00=01797 PECORARO, SHERRY A $46.0 $46.0 P0L9DSC3 CANCER 1 OOOMO1797 PECORARO, SHERRY A $62.54 $INN $62.54 $109.22 -continued on next page - COVERAGE TYPE(CT) IREMARKS (RMI I = Individual CV =Pending Conversion A=Add person to policy H = Name Change O = 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 1 of 2 Aflac PO Box 673025, Dallas TX 752673025 1-800-99-AFLAC (1.800-992-3522) Aflac.corn COPY - Original Invoice If paying by paper check, please reconcile online and send your check with the printed payment coupon to the address listed above. " Highlighted lines Indicate that tine premium amount being remitted Was adjusted and/or a Change Request was submitted for the employee. e premium amount billed for some policies may not reflect the number of deductions indicated above if thlicies were issued during the billing period. If paying by paper check, please reconcile online and send F ur check with the printed payment coupon to the address listed above. Policy Type CT Dept. Nama RM Premium Employee Adjusted Adjusted CR Member# Sub Total Premium Sub Total POB8KOA7 CANCER F 0000001750 PEREZ, FRANK $46.50 $45.50 $45.50 $45.50 POGMF1 ACC P REYES, EDDIE $S8.22 $38.22 POY443KI HOSP P REYES. EDDIE $133.52 $171.74 $133.52 $171.74 PDX152114 ACC I RODRIGUEZ, HAROLD $24.32 $24.32 P"152H5 HOSP I RODRIGUEZ, HAROLD $75.66 $99.98 $75.66 $99.98 P1326RA5 ACC I RODRIGUEZ, MICHAEL $24.32 $24.32 P1B26945 CANCER 1 RODRIGUEZ, MICHAEL $60.94 $85.26 $60.94 $85.26 P0T3Y4C9 HOSP 1 00000016M RODRIGUEZ, MICHAEL $47.32 $47.32 $47.32 $47.32 POBBM52 ACC F 000W01682 RODRIGUEZ, RICHARD $59.02 $59.02 MBBK358 CANCER F 00000(T682 RODRIGUEZ, RICHARD $48.80 $107.82 $48.80 $107.82 P088KOJO ACC P 0000001321 SAUNDERS, JANICE $33.28 $33.28 POB8KOK3 HOSP P 0000001321 SAUNDERS, JANICE $64.W $117.66 $84.38 $117.66 POV6211.12 ACC 1 DOOMO1879 SHELEY, CHERIEA $24.32 $24.32 $24.32 $24.32 P1C410P5 ACC I SMITH, ROY $24.32 $24.32 $24.32 $24.32 PUV6211_3 HOSP 1 000001TIM3 STEVENS,TANIAA $641,18 $"As P0V621U1 ACC I 00000U1343 STEVENS,TANIAA $24.32 $88.80 $24.32 $88.80 P088KOA4 ACC F OBOMOO946 THOMAS. AHMAD $46.68 $46.68 POBBK099 HOSP F OUDWOU946 THOMAS, AHMAD $63.18 $109.86 $63.18 $109.86 PDJSHIS6 ACC 1 ONWO1676 VASTA, MICHAEL $22.36 $22.36 $22.36 $22.36 P0HSA2F9 STD I WAKEN, CASSANDRA $76.06 $76.06 $76.06 $76.06 PWBHITI ACC S M0001173 WEST, COKENYA $35.76 $35.76 $35.76 $35.76 P0V621L4 ACC 1 0000001828 WESTBERRY, ANSON J $24.32 $24.32 $24.32 $24.32 POB8K355 ACC F 0000001403 WHITE, DEON $46.68 $46.60 $46.68 $46.68 P0Y4A937 ACC P WILLIAMS, DARIUS $38.22 $3822 P0Y4A938 HOSP F WILLIAMS, DARIUS $120.52 $158.74 $120.52 $158.74 POBSKOA3 ACC I Ooao001671 ZAPATA, MARLON $22.36 $22.36 $22.S6 $22.W Total Amount Billed: $2,659.621 Ant Due I $2,659.62 LEGEND COVERAGE TYPE (CT) REMARKS(RM) CHANGE REQUEST(CRI I = Individual CV = Pending Conversion A=Add person to policy H = Name Change O = Other F = Family PA = Policy is Paid Ahead C= Cancel Coverage I = Delete person from policy R = Retired S = Single -Parent Family PC = Policy is Pending Conversion D=Deceased L = Non -Family Medical Leave T = No longer employed here P = Primary -Spouse and Is Paid Ahead E=Unknown Insured -Remove M= Missed Deduction W = Transfer to another account F= Family Medical Leave Y = Military Leave Page 2 of 2 ma000J01mm3 �`nn ^,cmy3maAn a y D m T D y 3y M Z A A A ymj 1TTN 0 m� N N x x$ O O m D N O A O z 9 N� A n m� C C C O A A 0 0 V• m A y D D D 3 2< F Z D D O A < m ',O z D z m D D n D m g n rm- S z 3 S D 2 N Z O A O D m m D y 0 t � O A z a Z D O N A D O W A A V N mm Y W N V J N yW p m N N N O] m N A m A N O .. p O A O O A O > m J J 0 m m 0 Wmy N A N N N A A A W 4p L p W m pPi A T W N W 01 N U b N W N w g W N N N W N N N N mN W N W N mV1 W W N mJ1 N � N N m A 1Wn N N 10m W A A G V N b Y N 100 N N N W Ili N m W W W N J O v w JIY V Gm W W W mW N IO y [U m JW N W 4a W IY V N m P W N m W Of m O N N N W m .P O N W P N N m A O M N O m D y 2 yam_y 2 D 0 0 0 T T T n o_ D D m C A p m D .0a S T W m .t S1 --D1I O T 2 r 2 A A A N m p O f T T 2 OT. mT O O D y fOi) m~ Z m IJ yll O m m 2 2 m ` y T A O O y O O .11 �C1I C m C O A .T O `� D D O 0 T m O m p O A T D y 2 y 2 y< 2 y m N Q N O_ D O 2 9 3 m 2 a$ y 4 20 .lTl DCL 2 i D r O D m Z S nS n D T F m 2 m �' 0i 1 m�e < A m 0 O D D m D D m A o T m z r a Z $ o 1 6 < z 0 D S o W S g S o o S o oOR - S S- a-- $ o 0 ao 8 o a o o m a o 0 0 o a m i� Q O 6 a D_ 2 < � n n W m P r N O T A N W N �W A P P P m J V f Wf�� N �N U W W Y uWi R PW m WWV W 3 N N g— N 0 0 a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o m o 0 0 o m o 0 a o 0 g o 0 0 0 0 a a 00 a 0 o S g o 0 0 0 0 a a 0 0$$ 9 o 0 0 0 Fi O