HomeMy WebLinkAboutInv# 2024-00001265 - Fidelity Security Life Insurance Company - 12/26/2024 (3)SUMMARY INVOICE FOR:
INVOICE NUMBER:
SUBGROUP ID:
GROUP ID:
BILLING PERIOD:December, 2024
The City of Dania Beach COBRA
5000544
1001
166552632
FULL MONTH
COVERAGE TIER COUNT RATE TOTAL
Benefit Level 1
Employee Only 1 $4.39 $4.39
Employee + Family 1 $12.24 $12.24
FULL MONTH TOTAL $16.63
RETROACTIVE ADJUSTMENTS
Retro 11/2024 $12.24
RETRO ADJUSTMENT TOTAL $12.24
CURRENT BILLING PERIOD TOTAL $28.87
FIDELITY SECURITY LIFE INSURANCE CO.
PO BOX 632530
CINCINNATI OH 45263-2530
Remit To:
GROUP ID:
SUBGROUP ID:
INVOICE NUMBER:
TOTAL INVOICE AMOUNT DUE:
5000544
1001
166552632
$28.87
THE CITY OF DANIA BEACH COBRA
LINDA GONZALE
100 W. DANIA BEACH BLVD.
DANIA BEACH FL 33004
PAYMENT IS DUE IN FULL UPON RECEIPT
THE INVOICE CALCULATION IS BASED ON MEMBERSHIP AS OF 11/20/24
PLEASE DETACH AND RETURN
Forwarding Service Requested
THE CITY OF DANIA BEACH COBRA
LINDA GONZALE
100 W. DANIA BEACH BLVD.
DANIA BEACH FL 33004
2,291
EyeMed
4000 LUXOTTICA PL
MASON OH 45040-8114
J388 [2,291] 3 of 6
[DM-BS]
20241126B05J3883300 38195
12/20/24