249923 09/23/15 r.C�NM
CITY OF CARMEL, INDIANA VENDOR: 362876
® "¢1 ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: S"'"'6,034.68'
�• ,= CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK NUMBER: 249923
CHICAGO IL 60693 CHECK DATE: 09/23/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 489023 1,346.40 GENERAL INSURANCE
1205 4347500 489024 2,479.10 GENERAL INSURANCE
1205 . 4347500 489025 2,209.18 GENERAL INSURANCE
TRAY LERS J PAGE 1
DEDUCTIBLE / SELF- INSURED INVOICE
i
3036P64A-810 521GX7087 08/31/2015 000489025 09/15/2015 2,289.87
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL,CARMEL CLAY
13607 COLLECTIONS CENTER DRIVE ONE CIVIC SQUARE
CHICAGO, IL 60693 CARMEL IN 46032
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVE
PLEASE WRITE THE POLICY & ACCOUNT NUMBER ON OUR C�,�i -mittld To
AWAkSEP 2 1 2015 P GE 1
TRAVELERS)
THE TOTAL DUE INCLUDES PAST DUE C Vgk Treasurer
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
3036P64A-810 521GX7087 08/31/2015 000489025 09/15/2015 2,289.87
CURRENT
CLAIM#: CER1472 DATE OF LOSS: 03/26/2014
DESCRIPTION: BAUT AMBULANCE ON EMERGENCY RUN ON RANGELINE RD. , HE
WAS WAITING FOR T
CLAIMANT: SETH MATTINGLEY
LOSS 2,209. 18
CLAIM TOTAL 2,209. 18
CURRENT CHARGES $2,209. 18
ACCOUNT SUMMARY
CURRENT CHARGES 2,209. 18 INSURED NAME: CITY OF CARMEL,CARMEL CLAY
PAST DUE CHARGES 80.69 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 2,289.87
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 2,289.87
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE-HELPDESK@TRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1-860-277-6812 ANTONIO CONTRERAS
l HA t L t H5 J rmuc 1
DEDUCTIBLE / SELF- INSURED INVOICE
all i i
14N99887-ZPP 521GX7087 08/31/2015 000489024 09/15/2015 6,375.02
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL, CARMEL CLAY PARKS BUIL
13607 COLLECTIONS CENTER DRIVE ONE CIVIC SQUARE
CHICAGO, IL 60693 CARMEL IN 46032
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE O TRAVELERS.
PLEASE WRITE THE POLICY 8 ACCOUNT NUMBER ON Y UR CS"mitted To
AMW SEP 2 12015
TRAVELERS J P E 1
ale k
THE TOTAL DUE INCLUDES PAST DUE C Treasurer
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
14N99887-ZPP 5216X7087 08/31/2015 000489024 09/15/2015 6,375.02
CURRENT
:LAIMN: EXK1029 DATE OF LOSS: 12/02/2012
,ESCRIPTION: PLAINITIFF ALLEGES UNLAWFUL DETENTION DUE TO POLICE
RESPONDING TO THE
LAIMANT: JAMES BECKETT
LOSS 1 ,500.00
EXPENSE 3,952.40
CLAIM TOTAL 5,452.40
LAIMN: EYQ5411 DATE OF LOSS: 07/25/2012
ESCRIPTION: PROF C - CIMT WAS ARRETED BY THE MARION COUNTY DRUG
TASK FORCE AND CHA
LAIMANT: JONAH LONG
EXPENSE 32130
CLAIM TOTAL 321.30
CURRENT CHARGES $5,773.70
CCOUNT SUMMARY -
URRENT CHARGES 5,773.70 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
AST DUE CHARGES 601 .32 AGENT NAME: HYLANT GROUP INC
NAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
OTAL DUE 6,375.02
ISPUTED ITEMS 0.00
CCOUNT BALANCE G,375.02
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE-HELPDESK@TRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1-860-277-6812 ANTONIO CONTRERAS
Spelbring, James P - HR
From: Spelbring,James P - HR
Sent: Tuesday, September 15, 2015 2:14 PM
To: 'Lori Hood'
Subject: RE: City of Carmel Balance
Please apply the full amount of the credit to bill number 000489024 and we will submit a check for the remaining
$2,479.10.
Thanks,
Jim Spelbring
Office Administrator
City of Carmel Department of Human Resources
ipspelbring@carmel.in.gov
317-571-2465
From: Lori Hood [ma ilto:Lori.Hood @Hyla nt.com]
Sent: Tuesday, September 15, 2015 12:59 PM
To: Spelbring, James P - HR
Subject: RE: City of Carmel Balance
$3294.60
Lori Hood—CLCS Senior Claims Specialist
301 Pennsylvania Parkway I Suite 2011 Indianapolis, IN 46280
P 317-817-51531 F 317-817-5151 1
E lori.hood hvlant.com I www.hylant.com I
Nonecure
a ®
2nu .� REST
APHYLANT �BENTTF'Op"WqRK
For all the latest information on Health Care Reform,please visit our website at www.hvlant.com
From:Spelbring,James P- HR [mailto:ipspelbring@carmel.in.gov]
Sent:Tuesday, September 15, 2015 10:30 AM
To: Lori Hood
Subject: City of Carmel Balance
Lori,
DoY ou show we still have a credit balance?
1
I
Jim Spelbring
Office Administrator
City of Carmel- Human Resources Department
One Civic Square
Carmel, IN 46032
ipspelbring@carmel.in.gov
0: 317-571-2465
F: 317-571-2409
Notice: The contents of this communication are privileged and confidential. If you are not the intended recipient
of this transmission,you are hereby notified that distributing, copying, or disclosing this communication, or
reliance on the contents thereof, are strictly prohibited. If you have received this communication in error,
please notify the sender immediately, then destroy the original and all copies thereof.
i
TRAVELERS J PAGE 1
DEDUCTIBLE / SELF- INSURED INVOICE
iii�ljqi i
14T62033-ZLP 5216X7087 08/31/2015 000489023 09/15/2015 3,789.20
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL
13607 COLLECTIONS CENTER DRIVE ONE CIVIC SQUARE
CHICAGO, IL 60693 CARMEL IN 46032
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE[A .,
ELERS.
PLEASE WRITE THE POLICY & ACCOUNT NUMBER ON gfib mitte d T®
SEP 2 12015
TRAVELERS J PA E 1
erk Treasurer
THE TOTAL DUE INCLUDES PAST DUE C
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
iiiii'll ;j
14T62033-ZLP 521GX7087 08/31/2015 000489023 09/15/2015 3,789.20
CURRENT CLAIM#: EYQ7995 DATE OF LOSS: 10/11/2013
DESCRIPTION: PLAINTIFF ALLEGES FALSE ARREST.
CLAIMANT: CARL COOPER
EXPENSE 1 ,224.00
fi;S� CLAIM TOTAL 1,224.00
CLAIM#: E2SO202 DATE OF LOSS: 12/29/2014
DESCRIPTION: EPLI C- THOMPSON, JAMES L JR. EEOC COMPLAINT ALLEGING
RETALLIATION DUE
CLAIMANT: JAMES L THOMPSON
EXPENSE 122.40
CLAIM TOTAL 122.40
CURRENT CHARGES 46.4
ACCOUNT SUMMARY
CURRENT CHARGES 1 ,346.40 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 2,442.80 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 3,789.20
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 3,789.20
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE-HELPDESK@TRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1-860-277-6812 ANTONIO CONTRERAS
1
I
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))
08/31/15 000489024 applied $3294.60 Credit ($3,294.60)
08/31/15 000489025 $2,209.18
08/31/15 000489024 $5,773.70
08/31/15 000489023 $1,346.40
I 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
VOUCHER NO. WARRANT NO.
ALLOWED 20
Travelers
IN SUM OF $
13607 Collections Center Drive
Chicage, IL 60693
$6,034.68
ON ACCOUNT OF APPROPRIATION FOR
Administration Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1205 000489024 43-475.00 ($3,294.60) I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
1205 000489025 43-475.00 $2,209.18
materials or services itemized thereon for
1205 000489024 43-475.00 $5,773.70 which charge is made were ordered and
1205 000489023 43-475.00 $1,346.40 received except
Monday, September 21, 2015
Director, Administration
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund