The URL can be used to link to this page

247194 07/15/15 i G/ CITY OF CARMEL, INDIANA VENDOR: 362339 ONE CIVIC SQUARE CITIZENS MANAGEMENT INC CHECK AMOUNT: $*****1,170.00* CARMEL, INDIANA 46032 PO Box 620 CHECK NUMBER: 247194 '�'eruN 'r I HOWELL MI 48844-0620 CHECK DATE: 07/15/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 302 5023990 070715 1,170.00 OTHER EXPENSES i I I CMI, A York Risk Services Company, Inc. PO Box 620 2-�5 Self-Insurance Howell, MI 48844-0620 1-800-533-9366 x 3276 BILLING NOTICE Steve Engelking Date: July 7, 2015 City of Carmel Reference: City of Carmel One Civic Square Carmel, Ml 4,6032 Self-Insured Workers' Compensation Loss Fund Remarks: Claims Handling Excess Premium Policy Period: 01-01-14 to 12-31-14 Service Fee Billing Period: 01-01-14 to 06-30-15 Other $1,170.00 , (See Comments) Comments. The back-up documentation is attached. Please submit payment to the.address above Attn: Judy Theibert CMI - Submitted 'T® Electronic Banking Information Wells Fargo Bank,N.A. Summit,NJ JUL 13 2015 Account Name:Fox Hill Holdings,Inc.Depository Account Acct:2000039122915 ACH Routing#:021200025 Wire Routing#:1210002481 SWIFT ID#:WFBIUS6S Clerk Treasurer Total Amount Due: $1,170.00 By: August 7, 2015 PLEASE RETURN COPY WITH YOUR PAYMENT CityOfCarmel-CH-0715 07-06-15/CB ClientBill{SIW-3(2-91)1 CM1 A YORK RISK SERVICES COMPANY July 6, 2015 Steve Engelking City of Carmel One Civic Square Carmel, IN 46032 RE: City of Carmel Claims Handling Dear Mr. Engelking: i Enclosed you will find an invoice for policy term January 1, 2014 to December 31, 2014, billing period January 1, 2014 to June 30, 2015. The back-up documentation is attached. If you have any questions please feel free to give us a call. Thank you, Cassey Brooks Risk Management Services CMI 800-533-9366 X3279 Cassandra.brooks@cmi-yorkrsg.com Enclosure Third Party Administration•Risk(Management•Loss Control Services 645 W. Grand River Ave,Suite 1 Q0• Howell,MI 48843 • PO Box 620•Howell,MI 48844-0620 Phone 1 800-533-9366 Fax 1 517- 548 -9246 www. cmi -yorkrsg. com I I CMI Workers' Compensation Claims Handling Report SUMMARY City of Carmel Policy Period: 01-01-14 to 12-31-14 Billing Period: 01-01-14 to 06-30-15 COUNT RATE TOTAL Indemnity: 8 $900 $7,200 Medical: 118 $165 $19,470 Transfer to Indemnity 0 $735 $0 Report Only: 0 $0 $0 Other: 0 $0 $0 Gra rjd Total 126 $26,670 Actual Claims Handling Fee: $26,670 Claims Handling Fee Deposit: $25,500 (Refund)/Charge $1,170 I i CMI Workers'Compensation Claim Handling Report Summary City of Carmel Policy Period: 01/01/2014 Thru 12/31/2014 Billing Period: 01/01/2014 Thru 06/30/2015 Claimant Type Desc:Indemnity Claimant Type 8 Claimant Type Desc: Medical Claimant Type 118 Claimant Type Desc:Traisferred To Indemnity Claimant Type 0 Grand Total: 126 I Run Date:07/06/2015 09104:51 Run By:CXB City of Carmel-Confidential Page 1 of 1 CMI Workers' Compensation Claim Handling Report Indemnity Claim Listing City of Carmel Policy Period: 01/01/2014 Thru 12/31/2014 Billing Period: 01/01/2014 Thru 06/30/2015 -------------------------------------------------------------------------- Claim Claimant Entry Date Date of Injury ---------- ------------------------------------------------------------- i Claimant Type Desc:Indemnity 0385-14-00029 Stewart,Jeff 01/09/2014 01/07/2014 0385-14-00457 Giles,William Gregory 01/29/2014 01/18/2014 0385-14-01290 Sy,Rebecca 02/26/2014 02/17/2014 0385-14-03236 Drake,Carl 05/07/2014 04/11/2014 0385-14-03901 Thompson,James 01/28/2015 05/04/2014 0385-14-05743 Schmaltz,Hannah 07/11/2014 07/10/2014 0385-14-06405 Hughes,Crystal 08/07/2014 04/30/2014 0385-14-06999 Snow, Donald 11/19/2014 08/26/2014 Claimant Type 8 I i I i Run Date:07/06/2015 09:05:38 Run By:CXB City of Carmel-Confidential Page 1 of 7 r CMI Workers'Compensation Claim Handling Report Medical Claim Listing City of Carmel Policy Period: 01/01/2014 Thru 12/31/2014 Billing Period: 01/01/2014 Thru 06/30/2015 ------------------------------------------------------------------ Claim Claimant Entry Date Date of Injury ------------------------------------------------------- Claimant ___Claimant Type Desc:Medical 0385-14-00042 Paddock,Ronald 01/08/2014 01/06/2014 0385-14-00043 Mowery,Anthony 01/08/2014 01/05/2014 0385-14-00049 Viehe,Richard 01/08/2014 01/06/2014 0385-14-00236 Jent,Danny 01/15/2014 01/10/2014 0385-14-00241 Ellison,Chris 01/15/2014 01/15/2014 0385-14-00461 Haboush,David 01/23/2014 01/17/2014 0385-14-00579 Vanderbeck,David 01/28/2014 01/26/2014 0385-14-00784 Toney,James 02/04/2014 01/29/2014 0385-14-00886 Thomas,Barry 02/06/2014 02/04/2014 0385-14-00888 Sinn,Bryon 02/06/2014 02/04/2014 0385-14-00890 Hammer,Sarah 02/06/2014 02/05/2014 0385-14-01013 Wilson,Carlos 02/10/2014 02/07/2014 0385-14-01014 Marvel,Thomas 02/10/2014 02/04/2014 0385-14-01017 Reese,Aaron 02/10/2014 02/10/2014 0385-14-01020 Stindie,Kevin 02/10/2014 02/06/2014 0385-14-01299 Dawson,Gregory 02/18/2014 02/15/2014 0385-14-01304 Schmidt,Brian 02/18/2014 02/15/2014 0385-14-01306 Harris,Robert 02/18/2014 02/15/2014 0385-14-01313 Miser,William 02/18/2014 02/17/2014 0385-14-01360 Rice,Jonathan 02/19/2014 02/18/2014 0385-14-01599 Acosta,Linda 02/24/2014 02/21/2014 0385-14-01604 Wilson,Carlos 02/24/2014 02/19/2014 0385-14-01701 Booker,Ebony 02/25/2014 02/21/2014 0385-14-01886 Baskerville,Anthony 03/03/2014 03/01/2014 Run Date:07/06/2015 09:05:38 Run By:CXB City of Carmel-Confidential Page 2 of 7 i CMI Workers' Compensation Claim Handling Report Medical Claim Listing City of Carmel Policy Period: 01/01/2014 Thru 12/31/2014 Billing Period: 01/01/2014 Thru 06/30/2015 ------------------------------------------------------------------------ Claim Claimant Entry Date Date of Injury ----------__-.----------------------------------------------------------- 0385-14-02233 Jenkins, Daniel 03/11/2014 03/10/2014 0385-14-02237 Zellers,Andrew 03/11/2014 03/10/2014 0385-14-02239 Zellers,Andrew 03/11/2014 03/08/2014 0385-14-02442 Plumer,Charles 03/18/2014 03/14/2014 0385-14-02447 Vanderbeck,David 03/18/2014 02/03/2014 0385-14-02515 Rayle,Jacen 03/19/2014 03/17/2014 0385-14-02549 Luckoski,Todd 03/20/2014 03/19/2014 0385-14-02726 Workman,William 03/26/2014 03/25/2014 0385-14-02871 Watts,Trent 04/01/2014 03/26/2014 0385-14-02872 Reeves,Neil 04/01/2014 03/26/2014 0385-14-02873 Thompson,James 04/01/2014 03/27/2014 0385-14-02959 Griffin,Halie 04/03/2014 04/02/2014 0385-14-03002 Page,Katherine 04/04/2014 04/04/2014 0385-14-03025 Ellison,Christopher 04/07/2014 04/03/2014 0385-14-03027 Fisher,Charles 04/07/2014 04/05/2014 0385-14-03028Zellers,Timothy 04/07/2014 04/05/2014 0385-14-03047 Vielee,Alexander 04/07/2014 04/05/2014 0385-14-03087 Walker,Christopher 04/08/2014 04/08/2014 i 0385-14-03113 Mabie, Michael 04/09/2014 03/27/2014 0385-14-03231 Hughes,Crystal 04/14/2014 04/13/2014 0385-14-03407 Frost,Bruce 04/21/2014 04/16/2014 i 0385-14-03408 Paddock,Ronald 04/21/2014 04/20/2014 0385-14-03473 Harris,Robert 04/23/2014 04/22/2014 0385-14-03971 Morrow,Scott 05/08/2014 05/06/2014 0385-14-03976 Higginbotham, Lee 05/08/2014 05/06/2014 i Run Date:07/06/2015 09:05:38 Run By:CXB City of Carmel-Confidential Page 3 of 7 I CMI Workers'Compensation Claim Handling Report Medical Claim Listing City of Carmel Policy Period: 01/01/2014 Thru 12/31/2014 Billing Period: 01/01/2014 Thru 06/30/2015 ------------------------------------------------------------------------- Claim Claimant Entry Date Date of Injury ------------------------------------------------------------------------- 0385-14-04079 Toney,James 05/13/2014 05/11/2014 0385-14-04103 Miller,Adam 05/14/2014 05/13/2014 0385-14-04399 Maki,Suzanne 05/22/2014 04/26/2014 0385-14-04432 Troyer,Darin 05/23/2014 05/22/2014 0385-14-04434 Snow,Donald 05/23/2014 05/22/2014 0385-14-04474 Zellers,Timothy 05/27/2014 05/23/2014 0385-14-04500 1 Mitchell,James 05/27/2014 05/24/2014 0385-14-04598 Roemke,Brian 05/30/2014 05/18/2014 0385-14-04604 Morris,James 05/30/2014 05/29/2014 0385-14-04660 Webb,Gregory 06/02/2014 05/28/2014 0385-14-04782 Cummins,Frank 06/05/2014 06/04/2014 0385-14-04783 Marvel,Thomas 06/05/2014 06/03/2014 0385-14-04855 Hill,Nathaniel 06/09/2014 06/07/2014 it 0385-14-04857 Henry,David 06/09/2014 06/07/2014 0385-14-04859 Dunlap,Christopher 06/09/2014 06/07/2014 0385-14-05161 Hedrick,Nicholas 06/19/2014 06/17/2014 0385-14-05167 I Dean,Stephanie 06/19/2014 06/16/2014 0385-14-05170 Bouyer,Steven 06/19/2014 06/12/2014 0385-14-05367 Greiner,Brandon 06/26/2014 06/25/2014 0385-14-05370 Thompson,James 06/26/2014 06/25/2014 0385-14-05372 Sanford,Doug 06/26/2014 06/26/2014 0385-14-05874 VanVoorst,Robert 07/17/2014 07/16/2014 0385-14-05937 Condra,Kyle 07/21/2014 07/17/2014 0385-14-05940 Wilson Jr.,Carlos 07/21/2014 07/17/2014 0385-14-06159 Palmer,Cherrie 07/29/2014 07/16/2014 Run Date:07/06/2015 09:05:38 Run By:CXB City of Carmel-Confidential Page 4 of 7 CMI Workers'Compensation Claim Handling Report Medical Claim Listing City of Carmel Policy Period: 01/01/2014 Thru 12/31/2014 Billing Period: 01/01/2014 Thru 06/30/2015 ------------------------------------------------------------------------- Claim Claimant Entry Date Date of Injury ------------'------•------------------------------------------------------ 0385-14-06345 S elbrin ,James 08/05/2014 08/03/2014 P 9 0385-14-06356 Marvel,Thomas 08/05/2014 07/22/2014 0385-14-06357 Benbow,Kip 08/05/2014 07/22/2014 0385-14-06360 Condra,Kyle 08/05/2014 07/22/2014 0385-14-06381 Cummins,Frank 08/06/2014 07/22/2014 0385-14-06523 Young,Andrew 08/12/2014 08/08/2014 0385-14-06528 Etter,Melinda 08/12/2014 08/06/2014 0385-14-06688 Cox,Jordan 08/18/2014 08/06/2014 0385-14-06747 Griffiths,Pam 08/19/2014 08/19/2014 0385-14-06748 O'Brian,Mary 08/19/2014 08/16/2014 0385-14-06884 j Schlemmer,Paula 08/25/2014 08/18/2014 0385-14-06945 Harvey,Anthony 08/26/2014 08/22/2014 0385-14-07141 Fuchs,Jeff 09/02/2014 09/01/2014 0385-14-07291 Brant,Kenneth 09/05/2014 09/03/2014 0385-14-07293 Miller,Adam 09/05/2014 08/27/2014 0385-14-07414 VanNatter,Shane 09/10/2014 09/02/2014 I 0385-14-07415 Witsken,Steve 09/10/2014 09/09/2014 0385-14-07449 Spillman,Richard 09/10/2014 09/10/2014 0385-14-07621 Baskerville,Anthony 09/15/2014 09/10/2014 0385-14-07777 Cummins,Frank 09/18/2014 09/18/2014 0385-14-08133 Lafollette,David 09/29/2014 09/26/2014 0385-14-08466 Stewart,Jason 10/06/2014 09/26/2014 0385-14-08499 Hood,Bryan 10/07/2014 10/02/2014 0385-14-08551 Dockery,Andrew 10/07/2014 10/06/2014 0385-14-08589 Henry,David 10/08/2014 10/08/2014 Run Date:07/06/2015 09:05:38 Run By:CXB City of Carmel-Confidential Page 5 of 7 I CMI Workers' Compensation Claim Handling Report Medical Claim Listing City of Carmel Policy Period: 01/01/2014 Thru 12/31/2014 Billing Period: 01/01/2014 Thru 06/30/2015 ------------—--------------- --------------------------------------------- I Claim i Claimant Entry Date Date of Injury ------------------------------------------------------------------------- 0385-14-09255 Jones,Frazier 10/14/2014 10/13/2014 0385-14-09777 Paddock,Ronald 10/21/2014 10/19/2014 0385-14-09779 Isenberger,Anthony 10/21/2014 10/20/2014 0385-14-09780 Heinlein,Robert 10/21/2014 10/17/2014 0385-14-09980 Haus,Joshua 10/27/2014 10/18/2014 0385-14-10125 Foster,Johnathan 10/29/2014 10/28/2014 0385-14-10215 Tragesser,Jeffrey 10/30/2014 10/23/2014 0385-14-10491 Brady,Sean 11/06/2014 11/05/2014 0385-14-10720 Dawson,Gregory 11/12/2014 11/08/2014 0385-14-10724 Gugel,Mark 11/12/2014 11/06/2014 0385-14-10932 Higgins,Robert 11/17/2014 11/15/2014 0385-14-11000 Ransford,James 11/18/2014 11/17/2014 0385-14-11001 Navarrete,Juan 11/18/2014 11/18/2014 0385-14-11002 Benbow,Kip 11/18/2014 11/14/2014 0385-14-11209 Jenkins,John 11/24/2014 11/20/2014 0385-14-11653 I Haddock,Monica 12/08/2014 12/04/2014 0385-14-11805 Schalburg, Randy 12/11/2014 11/04/2014 0385-14-11806 Vanderbeck,David R 12/11/2014 12/09/2014 0385-14-12317 Browning,Timothy 12/29/2014 12/18/2014 Claimant Type 118 Run Date:07/06/2015 09:05:38 Run By:CXB City of Carmel-Confidential Page 6 of 7 I CMI Workers'Compensation Claim Handling Report Transferred To Indemnity Claim Listing City of Carmel Policy Period: 01/01/2014 Thru 12/31/2014 Billing Period: 01/01/2014 Thru 06/30/2015 ------------------------------------------------------------------------ Claim Claimant Entry Date Date of Injury ------------------------------------------------------------------------ Claimant Type Desc:Transferred To Indemnity Claimant Type 0 Grand Total: 126 I I I City of Carmel-Confidential Page 7 of 7 Run Date:07/06/2015 09:i 5:38 Run By:CXB Ci y 9 VOUCHER NO. WARRANT NO. Citizens Management Inc. ALLOWED 20 IN SUM OF$ PO Box 620 Howell, MI 48844-0620 $1,170.00- ON 1,170.00ON ACCOUNT OF APPROPRIATION FOR C \tjo F-K Cob? Fu Nz PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 07.07.15 $1,170.00 I hereby certify that the attached invoice(s), or _ bill(s) is (are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except Monday, July 13, 2015 Director, Administration Title Cost distribution ledger classification if claim paid motor vehicle highway fund Prescribed by State Board of Accounts City Form No.201(Rev.1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service,where performed,dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s)or bill(s)) 07/07/15 07.07.15 Workers Compensation Claims 01/01/14-12/31/14 $1,170.00 1 hereby certify that the attached invoice(s), or bill(s), is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 20 Clerk-Treasurer