HomeMy WebLinkAbout306192 w..c�,,,� CITY OF CARMEL, INDIANA VENDOR: 371353
�i' ONE CIVIC SQUARE STATE FARM INSURANCE SUPPORT CEI�iFcAK AMOUNT: $""""'"'30.00"
,?� CARMEL, INDIANA 46032 P.0.BOX 588002 CHECK NUMBER: 306192
1,y(rON,. NORTH METRO GA 30029-8002 CHECK DATE: 12/12/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2200 4239099 30.00 OTHER MISCELLANOUS
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StateFarm BALANCE DUE NOTICE
STATE FARM FIRE AND CASUALTY COMPANY POLICY NUMBER 94 CD C417 8
2702 IRELAND GROVE ROAD SURETY BOW
BLOOMINGTON ILLINOIS 61709 06/28/2016 TO 06/28/2024
6199 DATE DUE PLEASE PAY THIS AMOUNT
07/28/2016 $30.00
INSURED: PAYER
SCOTT,LISA
1922 ASHLEY WAY APT B PREMIUM $ 30.00
WESTFIELD, IN 46074 BALANCE DUE $ 30.00
DATE DUE 07/28/2016
OBLIGEE STATE OF INDIANA
I
PREMIUM PAYMENT IN FULL IS REQUIRED FOR SURETY BONDS. IF BOND IS NO LONGER
NEEDED, PLEASE CONTACT YOUR AGENT.
Thanks for leffing us serve you... Please keep this part for your record.
Agent HINES, LEE E Prepared: 08/16/2016
Telephone 319-804-5495
------------ Cut on this fine and mall the portion below with your payment----------------_____�_______
3tateFarM - MOVING?PLEASE SEE YOUR STATE FARM AGENT. 6199 PLEASS RETURN THIS PART WITH YOUR
Ca CHECK MADE PAYABLE TO STATE FARM
INSURED SCOTT, LISA DATE DUE PLEASE PAY THIS AMOUNT
POLICY NUMBER 94 CD 0417 8 SURETY BOND 07/28/2016 $30.00
Please contact your State Farm Agent
to make any policy changes.
Insurance Support Center
PO BOX 588002
NORTH METRO, GA 30029-8002
538.160 bA Rev.09-232010(F0290A) 129034.3 09-242015
OFFICE USE ONLY r 1Kb $30.00
Prepared: 08/16/2016