HomeMy WebLinkAbout305877 12/12/16 4" CITY OF CARMEL, INDIANA VENDOR: 371374 87.60
t ACUITY INSURANCE
CHECK AMOUNT: S"""'"`"
,rq ONE CIVIC SQUARE 2800 5 TAYLOR DRIVE CHECK NUMBER: 305877
,' CARMEL, INDIANA 46032 2800 S AY OR RIVE CHECK DATE: 12/12/16
M,C�oN. .
DESCRIPTION
NVOICE
DEPARTMENT ACCOUNT PO NUMBER OIVERPAYMENTR AMO BT-
.60
60 OTHER EXPENSES
102 5023990
VOUCHER NO._—WARRANT NO.
ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#orINVOI CE NO. ACCT#/TITLE AMOUNT I hereby certify that the attached invoice(s), or
DEPT.# 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
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
CITY" EL
JANIEs BRAN_-1RD, 1VIA1OR
December 5, 2016
Acuity Insurance
2800 S TAYLOR DRIVE
SHEBOYGAN, WI 53081
RE: Ticket#20165392:1 D.O.S. 09/22/2016 JOHN MILLER duplicate mileage
payments received. Claim#PK1917
Dear Acuity Overpayment,
Enclosed you will find a refund check in the amount of$87.60.
We received your payment on November 17, 2016 for $87.60.
On November 30 check received for the entire claim $762.60.
Overpayment invoice—refund issued to Acuity Insurance for $87.60.
If you have any questions, please feel free to contact me at(317) 571-2604.
Sincerely,
W44
Michelle T. Harrington
Billing Administrator
C.VZVEI. FII:E DFP_VtIMENT
SrF\BS A. Cot-rs HE DQ1 Alfl ERS
T«o CIVIC SQUARE, C_vRNIEL, I\ 46032 OFFICE 317.571.2600, FAy 317.571.2615
CARMEL FIRE DEPARTMENT
F �' .D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
1z (317) 571 2604 Federal ID#356000972
Patient Name: MILLER,JOHN
JOHN MILLER CARMEL FIRE DEPARTMENT
1594 MONUMENT ST 2 CIVIC SQUARE
NOBLESVILLE , IN 46060 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date= Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 12/05/16 990115243
Ticket# : 20165392:1
Date of Service: 9/22/2016
DETACH HERE
REFUND ACUITY $87.60 DUPLICATE PAYMENTS RECEIVED FOR MILEAGE ON THIS CLAIM.
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE '$0.00
Pay online at www.govpaynet.com with PLC#7487 Run Number 20165392:1
Online Payment will charge a service fee.
Dateof Service Description Pa`tientName Char1 "Mges) Datex �_Payment(s)
Charges
9/22/2016 *BASIC LIFE SUP MILLER, JOHN $675.00
9/22/2016 *MILEAGE MILLER, JOHN $87.60
---------------------------------
Charge Total: $762.60
Payments
Paid By: Invoice 09/22/16 $762.60
Paid By: ACUITY INSURANCE COMMERCIAL INSURANCE 11/17/16 ($87.60)
Paid By: ACUITY INSURANCE COMMERCIAL INSURANCE 11/30/16 ($762.60)
Paid By: ACUITY INSURANCE REFUND 12/05/16 $87.60
BALANCE $0.00