HomeMy WebLinkAboutInv# 2025-00000023 - Fidelity Security Life Insurance Company - 01/29/2025 (2)SUMMARY INVOICE FOR:
INVOICE NUMBER:
SUBGROUP ID:
GROUP ID:
BILLING PERIOD:January, 2025
The City of Dania Beach COBRA
5000544
1001
166596467
FULL MONTH
COVERAGE TIER COUNT RATE TOTAL
Benefit Level 1
Employee + Family 1 $12.24 $12.24
FULL MONTH TOTAL $12.24
RETROACTIVE ADJUSTMENTS
Retro 12/2024 ($4.39)
RETRO ADJUSTMENT TOTAL ($4.39)
CURRENT BILLING PERIOD TOTAL $7.85
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
166596467
$7.85
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 12/20/24
PLEASE DETACH AND RETURN
Forwarding Service Requested
THE CITY OF DANIA BEACH COBRA
LINDA GONZALE
100 W. DANIA BEACH BLVD.
DANIA BEACH FL 33004
15,951
EyeMed
4000 LUXOTTICA PL
MASON OH 45040-8114
J79C [15,951] 3 of 6
[DM-BS]
20241226B06J79C3300 38195
1/28/25