HomeMy WebLinkAboutInv# 2025-00000116 - Fidelity Security Life Insurance Company - 02/25/2025 (2)SUMMARY INVOICE FOR:
INVOICE NUMBER:
SUBGROUP ID:
GROUP ID:
BILLING PERIOD:February, 2025
The City of Dania Beach
5000543
1001
166641228
FULL MONTH
COVERAGE TIER COUNT RATE TOTAL
Benefit Level 1
Employee Only 124 $4.39 $544.36
Employee + 1 64 $8.33 $533.12
Employee + Family 56 $12.24 $685.44
FULL MONTH TOTAL $1,762.92
RETROACTIVE ADJUSTMENTS
Retro 01/2025 $33.29
RETRO ADJUSTMENT TOTAL $33.29
CURRENT BILLING PERIOD TOTAL $1,796.21
FIDELITY SECURITY LIFE INSURANCE CO.
PO BOX 632530
CINCINNATI OH 45263-2530
Remit To:
GROUP ID:
SUBGROUP ID:
INVOICE NUMBER:
TOTAL INVOICE AMOUNT DUE:
5000543
1001
166641228
$1,796.21
THE CITY OF DANIA BEACH
LINDA GONZALEZ
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 01/20/25
PLEASE DETACH AND RETURN
Forwarding Service Requested
THE CITY OF DANIA BEACH
LINDA GONZALEZ
100 W. DANIA BEACH BLVD.
DANIA BEACH FL 33004
7,395
EyeMed
4000 LUXOTTICA PL
MASON OH 45040-8114
JFAA [7,395] 4 of 6
[DM-BS]
20250128B07JFAA3300 38195
2/25/25
FULL ROSTER
ROSTER LISTING FOR:The City of Dania Beach
BILLING PERIOD:February, 2025
INVOICE NUMBER:166641228 To view dependent members, please see the Enrollment Report at
eyemed.com/eyemanage
RETRO ADJUSTMENTS LIST
EM Subscriber ID Last Name First Name Plan Start Period Date End Period Date Retro Period Rate Location Code
28272983000 CASERTA CHRISTINA Benefit Level 1 01/01/2025 01/31/2025 01/2025 ($4.39) termed
26265778100 CIGUENE MAUDELINE Benefit Level 1 01/01/2025 01/31/2025 01/2025 $12.24 NH eff 1/1/25
34671230300 CORTES ALVARO Benefit Level 1 01/01/2025 01/31/2025 01/2025 $12.24 NH eff 1/1/25
33430943300 GREEN CARL Benefit Level 1 01/01/2025 01/31/2025 01/2025 ($12.24) termed
34840912000 LANE-ROZEA AUSTIN Benefit Level 1 01/01/2025 01/31/2025 01/2025 $4.39 NH eff 1/1/25
26265763100 RIVIERE JOSEPH Benefit Level 1 01/01/2025 01/31/2025 01/2025 ($4.39) Retiree
26265763100 RIVIERE JOSEPH Benefit Level 1 01/01/2025 01/31/2025 01/2025 $8.33 Retiree added spouse
34840911000 STEWART KHIRY Benefit Level 1 01/01/2025 01/31/2025 01/2025 $4.39 NH eff 1/1/25
34671230000 WALL CHRISTINA Benefit Level 1 01/01/2025 01/31/2025 01/2025 $4.39 NH eff 1/1/25
26265771500 WHITAKER STEPHEN Benefit Level 1 01/01/2025 01/31/2025 01/2025 ($4.39) Retiree
26265771500 WHITAKER STEPHEN Benefit Level 1 01/01/2025 01/31/2025 01/2025 $8.33 Retiree added spouse
34731887600 WISE DILLION Benefit Level 1 01/01/2025 01/31/2025 01/2025 $4.39 NH eff 1/1/25
Total Retro Adjustments for 01/2025 $33.29
Total Retro Adjustments for the Month of February, 2025 $33.29
ROSTER REPORT