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HomeMy WebLinkAbout307137 01/20/17 (9, ) CITY OF CARMEL, INDIANA VENDOR: 371452 CHECKAMOUNT: $*******901.00* ONE CIVIC SQUARE BSA LIFESTRUCTURES INC CARMEL, INDIANA 46032 9365 COUNSELORS ROW CHECK NUMBER: 307137 INDIANAPOLIS IN 46240 CHECK DATE: 01/20/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 901.00 OTHER EXPENSES VOUCHER NO. WARRANT NO. — ALLOWED 20 �S—S-"TN SUM OF $ $ ON ACCOUNT OF APPROPRIATION FOR Board Members PO#or INVOICE 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 CIVF RMEL .JAMES BRAINARD, MAYOR January 5, 2017 BSA LIFESTRUCTURES INC 9365 COUNSELORS ROW INDIANAPOLIS, IN 46240 RE : OVERPAYMENT RUN#20165663:2 KATHERINE STURICH Date of Service 10/05/2016 WC-6018252447 Dear BSA LIFESTRUCTERS INC: Refund for.$901.00 will be issued to BSA LIFESTRUCTERS INC. A check was received from BSA LIFESTRUCTERS INC on 11/22/2016 for$901.00. On 01/04/2017;CNA sent a check for$901.00 this created overpayment. CNA the Worker's Compensation Insurance is responsible for this invoice. If you have any questions, please feel free to contact me at (317) 571-2604. Sincerely, Michelle T. Harrington EMS Billing Administrator CARMEL FIRE DEINIZIME\T STEVEN A. Coins HEADQUARTERS T\x o CIVIC SQUARE. CARMEL, IN 46032 OFFICE 17.771.2600, FAx 317.571.2615 CAM14 CARMEL FIRE DEPARTMENT g4�D, 2 CIVIC SQUARE CARMEL, IN 46032-2584 (317) 5712604 Federal ID#356000972 Patient Name: STURICH, KATHERINE B KATHERINE STURICH CARMEL FIRE DEPARTMENT BSA LIFESTRUCTURES INC 2 CIVIC SQUARE 9365 COUNSELORS ROW CARMEL, IN 46032-2584 INDIANAPOLIS , IN 46240 TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID THIS PORTION WITH YOUR PAYMENT 81/05/17 990115385 Ticket# : 20165663:2 Date of Service: 10/5/2016 DETACH HERE REFUND ISSUED TO BSA LIFESTURES INC $901.00 CHECK# 187607 FROM BSA AND DUPLICATE PAYMENT RECEIVED FROM CNA WORKER'S COMPENSATION IS RESPONSIBLE. MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE f> $0 00 t Pay online at www.govpaynet.com with PLC#7487 Run Number 20165663:2 Online Payment will charge a service fee. +� �'` ulcstx �t � �t � �s�.1r arxs.. p,a .„�t. + its v`a �. a e f 'S 'I Descnption< Pant Name �� s Charges) Daae Pa nt(s fi�. -�# v*"* ate. i :A .#,•S `�•x;,,r:zw Charges 10/5/2016 *ADVANCED LIFE STURICH, KATHERINE B $775.00 10/5/2016 *MILEAGE STURICH, KATHERINE B $126.00 --------------------------------- Charge Total: $901.00 Payments Paid By: / Invoice 10/05/16 $901.00 -�- Paid By: STURICH, KATHERINE B Payment ClG �87�01 11/22/16 ($901.00) CN14- Paid By: STURICH, KATHERINE B Payment CK4 1052-3 5�q� 01/04/17 ($901.00) Paid By: STURICH, KATHERINE B REFUND 01/05/17 $901.00 BALANCE $0.00 ate+- tF•$-,' a r- dVIi, CD q4^ y�ti gYs r' KA pi ir firms", e Show Q 6 Nk 3 e. h ! F44. k,rYk 3 'a- 1 Y�r {`5 6a yA ru Ln rn 4,7 40 Wit A AA WIN BY s# e i Lo 10 �i Z { © visar } a s g k (.� c0 3 v;m m EY. I t c0 ' $ i t Z U N CI j t Ireu�nala���unuu CNA ATTN CLAIM PO BOX 8317 CHICAGO IL 60660 8 CNA I N i 1iy3 O I u OCKFI95 m CARMEL FIRE DEPARTMENT 2 CIVIC SQUARE oCARMEL IN 46032 o RECEIVED JAN p 207 I i t I OMENS 'To expedite handling of your claim,please Include our claim number on all future correspondence to us. Claim Number � 342 3 8 mom lnsuredtcfent Claimant ATT A LIFE TRUCTUR INC STURICH KATHERINE 1 I 1 Date W Loss Total WC Ind to Date From.iMu Dates SuffIDT TRAN EXP Pay Amount 05 15 Code# Codes 10/05/16-10/05/16 MED 21 AT $901.00 i leeFll $901.00 .., ZONES Reason � PAT ID#990115385 10/28/2016 t� To onvxe timely delivery of your check,please verity that the address on this check is complete and correct.N not,please notify your claims representative with the correct Information.Thank you. ACOWF W24.13 PLEASE DETACH BEFORE CASHING --------------------------------------------------------- ---- ---------- CNA105235594 Continental Casualty company UNDERWRITTEN BY: Date Issued Baric Acct, Chicago,iL60004 VALLEY FORGE INSURANCE COMPANY 12/23/16 4759628092 • • '• • �• • • r • • ctattTl NUIrA1Er a Do*Code MIWedYClknt IS-N Oif, i-' 3 342 34 GB B A`LIFE TRUCTU NC tJo. ' 20 PreTa a baa t+a CIsrnant Data of Los# WC 6018252447' STURICH KATHERINE' -10/05116 Frtlm pru IDates) - In Payment or a i !0 05 1 10/05/16 PAT ID#9 1153 5 1 8 2 16 PAY NINE HLIaMi'EO ONE AND NO1100THS' '-=------- ----------------_---- --------- To -CARMEL FIRE DEPARTMENT •r.w<•:.5907.00 Tt1E 2-CIVIC SOUARE t�ER' CARMEL IN 46032 - "Dir NOT CASHED IN SIX MONTHS I Web Fttryo Bar*.KA FROM MON1N OF ISSUE i u•OLOS 235694,1• I:053LOL56L1: 475962809211' 1