HomeMy WebLinkAboutCORRESPONDENCE - PURCHASE ORDER - 9153893Colorado Firefighter Heart and Circulatory Benefits Trust
COVERAGE YEAR 2016 INVOICE
Organization:
Poudre Fire Authority
102 Remington Street
Fort Collins, CO 80524
16GFHT-0007-0566 1 06960 1 07/01 /2015
Reimbursement from
to FOI-Tirrte Flreflgti,'.
in the fire prevention service
others benefit qualiifcafions
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Approval
Account /191�:S/D
MO/PO
OV Batch
1035)O,591000
Accepted by:
Pro Rata Factor x 1.0000
Total = $22,400.00
Credit -
Annual Total Member
Contribution
06/30/2016 1 06/11 /2015
Reimbursable
from DOLA
ID
$,150,00 j
$0 00
'il'llt I
12
iii %.00 I
' $1800.00
1.0000
$1, 800.00
$1,800.00
$22,400.00
Date: /S
To effect coverage, please sign, date, and return this Form with payment before the requested effective date.
Scan or fax is acceptable. This Invoice itself does not bind coverage. Named Organization must adopt the
Resolution to join the Benefits Trust and sign the Trust Agreement. Payment must be received prior to inception
of coverage.
Please Remit to: Colorado Firefighter Heart and Circulatory Benefits Trust
c% McGriff, Seibels & Williams, Inc.
P.O. Box 1539
Portland, OR 97207-1539
Toll Free: 844-769-6650 / Fax: 503-943-6622 Print Date: 06/11/2015