HomeMy WebLinkAboutInv# 2024-00001152 - Fidelity Security Life Insurance Company - 11/21/2024 (5)EyeMed
4000 LUXOTTICA PL
MASON OH 45040-8114
Forwarding Service Requested
5,480
THE CITY OF DANIA BEACH COBRA
LI NDA GON7.ALF.
100 W. DANIA BEACH BLVD.
DANIA BEACH FL 33004
BILLING PERIOD: November, 2024
FULL MONTH
COVERAGE TIER
Fc41 �NY6
N,
10, W I1F
117D 15A901 lot'M1
IDu-Dsi
SUMMARY INVOICE FOR: The City of Dania Beach COBRA
GROUP ID: 5000544
SUBGROUP ID: 1001
INVOICE NUMBER: 166508858
COUNT RATE TOTAL
Benefit Level 1
Employee Only 1 $4.39 $4.39
FULL MONTH TOTAL $4.39
CURRENT BILLING PERIOD TOTAL $4.39
---° PAYMENT IS DUE IN FULL UPON RECEIPT
' THE INVOICE CALCULATION IS BASED ON MEMBERSHIP AS OF 10/20/24
PLEASE DETACH AND RETURN
Remit To: FIDELITY SECURITY LIFE INSURANCE CO.
PO BOX 632530
CINCINNATI OH 45263-2530
THE CITY OF DANIA BEACH COBRA
UNDA GONZALE
100 W DANIA BEACH BLVD.
DANIA BEACH FL 33004
GROUP ID:
5000544
SUBGROUP ID:
1001
INVOICE NUMBER:
166508858
TOTAL INVOICE AMOUNT DUE:
$4.39