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Home My WebLink About250879 10/21/15 VENDOR: 362876 CITY OF CARMEL, INDIANA ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $*****4,598.05* CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK NUMBER: 250879 CHICAGO IL 60693 CHECK DATE: 10/21/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1205 4347500 490676 612.00 GENERAL INSURANCE 1205 4347500 491348 1,331.10 GENERAL INSURANCE 1205 4347500 491383 4,373.83 GENERAL INSURANCE 1205 4347500 CREDIT -1,718.88 GENERAL INSURANCE fent it Trans tO Date 06e Date Trans Description AMOU111. Workers'Compensation Policy# BL04659054 Effective: 111/14 111115 Issuing Company Great American E&S Ins Co 625154 1/1/2014 9/11/2015 AUDI AUDIT OCCUPATIONAL ACCIDENT LAYER (1,718.88) AUDIT PERIOD 111114-15 Total Invoice Balance: "PLEASE NOTE REMITTANCE ADDRESS CHANGE** IR HYL.A.NT Hylant-Indianapolis 301 Pennsylvania Pkwy,Ste 201 Indianapolis IN 46284 91111201` City of Carmel Loan# -- — Invoice#90829 UBAMA1 Page 1 of 1 COMPANY 9Y OCCUPATIONAL ACCIDIENT BUFFER LAT'ER INSURANCEI POLICY S WSURAKE CONTRACT IS WITH AN INSURER NOT LICENSED TO TRANSACT RV9UNC E'4 S.S'I'ATE Al" l'IS I UED AND I ELMERED AS A SURPLUS Ll COVERAGE P€RWANT TO ME I1Yl@IANA SWA`I'NS. D.RCLARATIO zS I`I'Elk�1.. a a��ic�i�e�lalec I�ff�rca��a�u: Name.andAddress.off. Name6IasFzred: 1'tilicV'1�' abet City of:carmel: BL04659054 Q'rLC�Ej�bC.S�UarL� C ca nel,lndzana 46032 ITHM1 :x: #6l¢cy Period: ) fkctive Ikate: 12:0:1 A.M.on January 1,2014 ou Date:: 12:01-A.M.an.Ianumy 1,2015 ITEM 3:. EIagi-bffity and Rates Eligibility:. A11.En loyees of the Insuredwho areActively at Work,as defined,respectively, in.t .e;Pakioy,while the Policy is-in faice. Covered Classes& ass Co es 55.06 Street&RoazY•Gomtrudiot, 8810 Clerical 7570 Water W.Ofks.operatio 8820 Att-€rneys '75'80 Sewage Disposal 98.69 Child Day care 7699 FireftgUers-Meal O&y 9060 clubs 7720 Police Oi'fcezu 91.02 larks NOC 7:725 Pdfice-Medical Only 9410 Iv,u&eipal Hmplay€es 8742 Community. Relations R.;ate.,per 5100 of Payroll: Estirnated Annual Payresll: ,3G5.f14f3 Mataner o[Premium,Payment-, AnfiugM ITF,rvl4. Preaatina t and.Premium Tax Statement-(premium to be adjusted'at ra rate-per$100 of l9yn'o8) a. Estimated.Annuat Premiiarm .. _............. V. Surplus•lines tax of2.5%ofEstimated Annua]Piemiurn.......... ......................_—S G. stamping fee of 0%of Estimated Annual Premivau....................,..................... NIA. c1. Other State Fees and Surcharges............................................,....w............_,......._... .3 NfA ..........._.,_.. ........................ ? AES4355(4111} Page 1 of 3 I _ city of Carmel 9LO46-59054 PMMWm Adjust€me"t for January 1,20-14-to January 1,2015 Actual Annual Payroll 37,107,347:00 Rate per$100 of Payroll O.00D4.0367 Ceded Premium 14;979.12 Less laid Pre-mum. 16,698;00 Minimum Premium Additional Prem..[urn Due Midwest Employers Casualty Company Audit'Statement Insured: City of Carmel Polity No.--., WCOOSS73 P I oficffem: 01/01/2014-to.0.1/0,1/2015 Audit Retiod: 01/'01.12014 -01101/1-015 State Cc& Clais-tT1166W Audited Rate-per Audited Payroll 3100-6f Premium Payroll IN 5-506 SUEET-09 ROA6 CONSTRUCTiON 12,5526,1411 5.33 $13+4 643 IN 7520 WATERWORKS OPERATION V,423.2.1`3. 3i00 372X98 IN. 7580 SLWAG-.E:DISP0SAL.PLANTQPC--R $1,862,435. 7-46 IN 76,S9 FIREFfGHTER-S&.DAIVERS $11.1090,016 2.74 $303-j866 fN: 7720 POLICE OFFICERS&I&IVERS $133j415 2.66 $34.40 7.72.5 POLICE.OFFICERS--MEDICAL ONLY $7,8931052 2JI $166543. IN 8.742 SALESFMS,0h5: $2574,22b .36 sq-ts IN 8810 CLERXAL OFFICE OR.L(URAR18 .20 (N 8-820 A.M.- $34&,80 .13 $453 IN 8-869 CHfLD DAYCARE CENTER-PROF%CLER 51,632,889- 1.24 $20i249 IN 9060 CLUBS-COUNTRY GOLFIFISHING $410,508 1.4.5 $5,95-2 IN 9102: PARK:AtL 9MPL4VEE-S&.DR4VVERS S1,952j31 0- 3.00 1~58i-569 K 941 U MUNICIPAL EMPLOYEE AbC' 1164-068. 2.73 $20,861D Total Payroll: $37,167,347 'Total Audited Premium- S845,74-2 (4) Experience Modification Factor, ft Other'Modification Factor: 1.000060000 Audited*Normal Prerdlum,,. $845,742 445% Earned Premium, 0064 Minimum Premium,-. $'41,166 Flat Chaeqes: $0 Earned Premium&Charges after Audit- $41,864 Leas Deposit Premiums-Cdfiected: $45,740 AddRidnal,(Retura'Premfum Duia: -$3j976 At1D-QNE-2 Page 1 of 1 Date Printed, 04¢07/2015 TRAVELERS PAGE 1 THIS ACCOUNT IS SCHEDULED TO GO TO A COLLECTION AGENCY IF PAYMENT IS NOT RECEIVED ON OR BEFORE THE DUE DATE. 3036P64A-810 5216X7087 09/30/2015 000491383 10/15/2015 4,373.83 CURRENT CLAIM#: E2J9721 DATE OF LOSS: 11/07/2014 DESCRIPTION: DONLEN TRUST, INSD WAS OPERATING A STREET SWEEPER AND WHILE HE WAS CLAIMANT: /DONLEN TRUST LOSS 4,322.63 CLAIM TOTAL 4,322.63 CURRENT CHARGES $4,322.63 ACCOUNT SUMMARY CURRENT CHARGES 4,322.63 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PAST DUE CHARGES 51 .20 AGENT NAME: HYLANT GROUP INC UNAPPLIED PAYMENTS 0.00 AGENT PHONE_: (317_) 817-5000 TOTAL DUE 4,373.83 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 4,373.83 CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE. FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE-HELPDESK@TRAVELERS.COM OR CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1-860-277-6812 ANTONIO CONTRERAS 322• �3 Submitted To 2 , G'03 OCT 19 2015 Clerk Treasurer TRAVELERS NON-FUNDED DEPARTMENT ONE TOWER SQUARE -9CR HARTFORD, CT 06183 00613 38742 CITY OF CARMEL,CARMEL CLAY ONE C I V I-C SQUARE CARMEL IN 46032 N a r m m m m a 0 0 0 N O Q O N TRAVELERS/ J PAGE 1 THE TOTAL DUE INCLUDES PAST DUE CHARGES. PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY. NUMBERPOLICY i DATE BILL NUMBER PAYMENT DUE TOTALDUE 14N99887-ZPP 521GX7087 09/30/2015 000490676 10/15/2015 3,906.60 T7 /J'-Tk C� CURRENT CLAIM#: EYQ5411 DATE OF LOSS: 07/25/2012 DESCRIPTION: PROF C - CIMT WAS ARRETED BY THE MARION COUNTY DRUG TASK FORCE AND CHA CLAIMANT: JONAH LONG EXPENSE 612.00 CLAIM TOTAL 00 CURRENT CHARGES (:$:612:.00 ACCOUNT SUMMARY CURRENT CHARGES 612.00 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN PAST DUE CHARGES 3,294.60 AGENT NAME: HYLANT GROUP INC UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000 TOTAL DUE 3,905.60 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 3,906.60 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 Submitted To OCT 19 2015 Clerk Treasurer TRAVELERS NON-FUNDED DEPARTMENT ONE TOWER SQUARE -9CR HARTFORD, CT 06183 00611 38746 CITY OF CARMEL, CARMEL CLAY PARKS BUIL ONE CIVIC SQUARE CARMEL IN 46032 n m m n co 0 m a 0 0 0 N O a 0 N TRAVELERS PAGE 1 THIS ACCOUNT IS SCHEDULED TO GO TO A COLLECTION AGENCY IF PAYMENT IS NOT RECEIVED ON OR BEFORE THE DUE DATE. :11mill] 14TG2033-ZLP 5216X7087 09/30/2015 000491348 10/15/2015 3,773.90 ";? CURRENT CLAIM#: EYQ7995 DATE OF LOSS: 10/11/2013 DESCRIPTION: PLAINTIFF ALLEGES FALSE ARREST. CLAIMANT: CARL COOPER EXPENSE 1,101.60 CLAIM TOTAL 1, 101.60 CLAIM#: E4E1787 DATE OF LOSS: 03/07/2014 DESCRIPTION: CLAIMANT ALLEGES THAT POLICE USED AXCESSIVE FORCE CAUSING BODILY INJUR CLAIMANT: LOUIS R PASTORE EXPENSE 229.50 CLAIM TOTAL 229.50 CURRENT CHARGES $1,331.10 ACCOUNT SUMMARY CURRENT CHARGES 1,331 .10 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN PAST DUE CHARGES 2,442.80 AGENT NAME: HYLANT GROUP INC UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000 TOTAL DUE 3,773.90 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 3,773.90 CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE. FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE-HELPDESK@TRAVELERS.COM OR CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1-860-277-6812 ANTONIO CONTRERAS ub �$te �® OCT 1 9 2015 Clerk Treasurer TRAVELERS NON-FUNDED DEPARTMENT ONE TOWER SQUARE -9CR HARTFORD, CT 06183 00612 38744 CITY OF CARMEL ONE CIVIC SQUARE CARMEL IN 46032 a a n m m a m v O O O N O Q O O VOUCHER NO. WARRANT NO. ALLOWED 20 TRAVELERS 13607 COLLECTIONS CENTER DRIVE IN SUM OF$ CHICAGO, IL 60693 $4,546.85 ON ACCOUNT OF APPROPRIATION FOR PO#/Dept. INVOICE NO. ACCT#/Fund AMOUNT Board Members 000490676 43-475.00 $612.00 1 hereby certify that the attached invoice(s), or 1205 101 000491383 43-475.00 $2,603.75 bill(s) is (are)true and correct and that the 1205 101 000491348 I 43-475.00 I $1,331.10 materials or services itemized thereon for 1205 101 which charge is made were ordered and received except Monday, October 19, 2015 Director 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 Date Invoice# Description Amount Dept. - Fund# (or note attached invoice(s)or bill(s)) 09/30/15 000490676 $612.00 1205 101 09/30/15 000491383 apply audit credit of$1718.88 to this invoice $2,603.75 1205 101 09/30/15 I 000491348 I I $1,331.10 1205 101 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