HomeMy WebLinkAbout259433 06/10/16 (9,
CITY OF CARMEL, INDIANA VENDOR: 362876
ONE CIVIC SQUARE TRAVELERS CHECKAMOUNT: $****16,014.22*
CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK NUMBER: 259433
CHICAGO IL 60693 CHECK DATE: 06/10/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 503317 3,702.05 5216X7087
1205 4347500 503318 6,350.17 5216X7087
1205 4347500 H810303GP64A 5,962.00 GENERAL INSURANCE
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995)
TRAVELERS ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
13607 COLLECTIONS CENTER DRIVE IN SUM OF$ CITY OF CARMEL
An invoice or bill to be properly itemized must show:kind of service,where performed,dates service
CHICAGO, IL 60693 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
$16,014.22 Payee
ON ACCOUNT OF APPROPRIATION FOR Purchase Order#
General Administration Terms
Date Due
PO# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
503318 43-475.00 $6,350.17 1 hereby certify that the attached invoice(s),or 5/31/16 503317 $3,702.05
1205 101 1205 101
503317 43-475.00 $3,702.05 bill(s)is(are)true and correct and that the 5/31/16 503318 $6,350.17
1205 101 materials or services itemized thereon for 1205 101
H-810-3036P64A-I 43-475.00 I $5,962.00 6/7/16 I H-810-3036P64A-I I $5,962.00
INDA-15 which charge is made were ordered and INDA-15
1205 101 1205 101
received except
Tuesday,June 07,2016
ZZL-la-Z r
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
Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
TRAVELERS J� PAGE 1
DEDUCTIBLE / SELF- INSURED INVOICE
POLICY : TOTAL
14TG2033-ZLP 5216X7087 05/31/2016 000503317 06/15/2016 3,702.05
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL, CARMEL CLAY PARKS
13607 COLLECTIONS CENTER DRIVE ONE CIVIC SQUARE
CHICAGO, IL 60693 CARMEL IN 46032
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS.
PLEASE WRITE THE POLICY & ACCOUNT NUMBER ON YOUR CHECK.
--------------------------------- -
TRAVELERSJ PAGE 1
POLICY NUMBER ACCOUNT NUMBER BILL DATE BILL NUMBER PAYMENT DUE TOTAL DUE
14TG2033-ZLP 521GX7087 05/31/2016 000503317 06/15/2016 3,702.05
CURRENT
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 30.80
C��U1'tc� CLAIM TOTAL 30.80
CLAIM#: E4E1787 DATE OF LOSS: 03/07/2014
DESCRIPTION: CLAIMANT ALLEGES THAT POLICE USED AXCESSIVE FORCE
CAUSING BODILY INJUR
CLAIMANT: LOUIS R PASTORE
EXPENSE 1,062.60
CLAIM TOTAL 1,062.60
CLAIM#: E4E8697 DATE OF LOSS: 12/29/2013
DESCRIPTION: GLIA C-REED, ANTHONY TORT NOTICE ALLEGING THAT HIS
VEHICLE AND PERSONA
CLAIMANT: ANTHONY W REED
EXPENSE 1,878.80
CLAIM TOTAL 1,878.80
CLAIM#: ESK2107 DATE OF LOSS: 08/18/2015
DESCRIPTION: EXCESSIVE FORCE
CLAIMANT: THOMAS BARNETT
EXPENSE 598.90
CLAIM TOTAL 598.90
CLAIM#: ESK7258 DATE OF LOSS: 04/02/2016
DESCRIPTION: GLIA C - LOPEZ, LINDSEY TORT NOTICE ALLEGING DAMAGE TO
A MAILBOX WHEN
CLAIMANT: LINDSEY LOPEZ
Submitted T® LOSS 130.95
CLAIM TOTAL 130.95
JUN 0 6 2016 CURRENT CHARGES $3,702.05
TRAVELERS.1 PAGE 2
DEDUCTIBLE / SELF- INSURED INVOICE
: i
14T62033-ZLP 521GX7087 05/31/2016 000503317 06/15/2016 3,702.05
ACCOUNT SUMMARY
CURRENT CHARGES 3,702.05 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 3.702.05
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 3,702.05
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 1-860-277-2354 GREG POST
TRAVELERS J PAGE 1
DEDUCTIBLE / SELF-INSURED INVOICE
3036P64A-810 5216X7087 05/31/2016 000503318 06/15/2016 6,350. 17
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 TRAVELERS.
PLEASE WRITE THE POLICY & ACCOUNT NUMBER ON YOUR CHECK.
TRAVELERS/ J PAGE 1
3036P64A-810 5216X7087 05/31/2016 000503318 06/15/2016 6,350. 17
CURRENT
CLAIM#: E3K1860 DATE OF LOSS: 04/06/2016
DESCRIPTION: BAUT C - JEWELL, CHRISTOPHER IV FOOT SLIPPED OFF THE
BRAKE AND SHE STR
CLAIMANT: CHRISTOPHER JEWELL
LOSS 1,506.65
CLAIM TOTAL 1,506.65
CLAIM#: E3Q1143 DATE OF LOSS: 11/15/2015
DESCRIPTION: 3 VEH ACC - IV REARENDED OV1 STOPPED - OV1 WAS PUSHED
INTO OV2 STOPPED
CLAIMANT: FRANK C WILLOUGHBY
LOSS 1,016.32
CLAIM TOTAL 1,016.32
CLAIM#: E3Q6036 DATE OF LOSS: 04/27/2016
DESCRIPTION: BAUT C - UTKEN, MELINDA IV WAS BACKING OUT OF A
PARKING SPACE WHEN OV
CLAIMANT: MELINDA UTKEN
LOSS 2,255.00
CLAIM TOTAL 2,255.00
CLAIM#: E3Q6266 DATE OF LOSS: 05/06/2016
DESCRIPTION: IV WAS BACKING INTO A PARKING SPOT AND THE IV MIRROR
HIT THE OV THAT W
CLAIMANT: KELLY BOUCHEZ
LOSS 1 ,572.20
CLAIM TOTAL 1,572.20
CURRENT CHARGES $6,350.17
Submitted To
S"b
N 0 6 2016[JU
rk Treasurer
TRAVELERS J PAGE 2
DEDUCTIBLE / SELF-INSURED INVOICE
1211 qDymillillyj Il I
3036P64A-810 521GX7087 05/31/2016 000503318 06/15/2016 6,350.17
ACCOUNT SUMMARY
CURRENT CHARGES 6,350. 17 INSURED NAME: CITY OF CARMEL,CARMEL CLAY
PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 6,350.17
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 6,350. 17
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 1-860-277-2354 GREG POST
�Tzs'
�C Premium Audit'.
/�
'PO.Box 2927 : . '.. . .
TRAVELERS.) Hartford;CT'.06104-2927
THE TRAVELERS INDEMNITY COMPANY
Premium Ad ustment:Notice. fH/s fS;aora eaL • 4
CITY OF CARMEL olicy.Number H=810-3036P64A-IND-15
ONE:CIVIC SQUARE . . Submitted To:
Policy Period:.01/01/2015 to 01/0:1/2016:
CARMEL,:IN 46032 Audit Period: 01/0172015 to 01%01/2016
JUN 0 6:2016
Issue Office: 24717
G8433 Date,of This Notice: 2/2912016
Clerk p. asuc�
HYLANT.GROUP INC. . Mode of Adjustment ANNUAL AUDIT.
301:PENNSYLVANIA PKWYa.
. . .INDIANAPOLIS,:IN 46280
'.Total Eemed:Premium $: 213;449:00 '
Audit Contact: 'Pr'e'mium Prior to Audit : $ 267,487.00
CUSTOMER SERVICE'(GL) Additional Premium Due',
1-800=842;4271 : : Return:Premium $ uo
"Premium Prior to Audit"includes the original policy premium and.any:
•
endorsements•d
uring'the,policy term
This does not reflect actual,payments made.
THIS ADJUSTMENT STATEMENT.WAS:PREPARED FROM:A ReportYou;Submitted: '
ra4� �ra x ca E "ALA 1—LEARNED PREMI-Tci,r- s ,CLASS PREMIUM COMff. PaD COMP.O,TIONS� CODES I<EY {v BASIS B^I;LIAB LItiBtMB!Ij'16B� IIA
COMPOSITE RATED ,.
POLICY AS ISSUED.
LIABILITY
POWER UNITS U 426.00 509.000 212,412.00
COMPREHENSWE.
OCN F• 18,457,159:00 0:122 27,492:00
COLLISION
OCN'.: F 18,457,159.00 0.149 27,583:00
AUDITED RESULTS' . . '..
LIABILITY,POWER UNITS U : 8.50 '509.000 4,327.00
COMPREHENSIVE,OCN. '.: F: 603,500.00 . . 0.122 736.00.
COLLISION OCN . F 603;500:00 0.149