311240 05/09/17 t
��' ��'`• CITY OF CARMEL, INDIANA VENDOR: 362876
ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $****19,039.60*
,3 ?�; CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK NUMBER: 311240
-CHICAGO IL 60693 CHECK DATE: 05/09/17
-9 IIUN
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 000520012 17,662.00 GENERAL INSURANCE
1205 4347500 000520013 1,377.60 GENERAL INSURANCE
n n -L ® $ «
\ ) ` ) § 2 z 0 - / 7_
} D n E
n #
p O m m
\ § § z O k / 0 /
$ S S \ § - @ ® 0)
( § § k A O 6 k
# -nm
CD
/ CL 3 z
]�
k : B ®
/ f , t ƒ 0 k O q /
£ § e ) a i g ; Q m
/ 8 8 0 7 7 D
& 2 w m 2
w
§ ? 2
> -n§
0 |
\
i, m
= o o w
7 a
Z e r
, < = 7 $ i °
PL 0 f \ a k §
0
0
E § 7 -
\
§
$ a W
E - C Z
§ m ■ 38 ,
OD 0 k k =
k
C? 7 [
4 7
B k k
Z -
o E
kq 2 S qo g (A
33 j m k (A
> \
0 \ Crr E
§� � \ \ E I @ ' 0
\ � al z g ] Q §
A k ) e ) 2 q J k \ C
; 0 $ƒ k /
:r%E } }
�0
\/ G_ /
3 a \ k � D
)o ) 0 a E
�E g3 t
2 E 2 o \
» �
/ 0j U CD � � r
¥ ƒ % ] i { C
% ( \ / \
E $ n
B CLk 2 M \
c § m D \ ]
CD # z
A_ 60 > �CD }
& § -
E § -4 E
C) ) ® k
AgW
PAGE 1
TRAVELERS J
DEDUCTIBLE / SELF- INSURED INVOICE
gimWERIETTICNIVIM, 1101MRIET11: 1JUIIIWIJA
303GP64A-810 5216X7087 04/28/2017 000520013 05/15/2017 1 ,377.60
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.
AIM
TRAVELERS ) PAGE 1
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
• 1141wm ki III N 13 EMNA1111 I 1917M.14 vm:l ILI IM. ; 1
3036P64A-810 521GX7087 04/28/2017 000520013 05/15/2017 1,377.60
CURRENT CHARGES
CLAIM#: ESR5763 DATE OF LOSS: 03/20/2017
DESCRIPTION: IV AND OV WERE BOTH STOPPED AT STOP SIGN, OV BEGAN TO
GO AND THEN STOP
CLAIMANT: STANLEY W FITZGERALD
LOSS 874.95
CLAIM TOTAL 874.95
PAST DUE CHARGES
CLAIM#: E3Q9166 DATE OF LOSS: 08/07/2016
DESCRIPTION: BAUT C - MILLER, MICHAEL IV AND OV WAS PASSING ON W
136TH ST WHEN THEI
CLAIMANT: MICHAEL H MILLER
LOSS 502.65
CLAIM TOTAL 502.65
TOTAL CLAIMS) DUE $1,377.60
Submitted To
MAY 0 8 2017
Clerk Treasurer
TRAVELERS PAGE 2
DEDUCTIBLE / SELF-INSURED INVOICE
flifiliffilill
3036P64A-810 521GX7087 04/28/2017 000520013 05/15/2017 1 ,377.60
ACCOUNT SUMMARY
CURRENT CHARGES 874.95 INSURED NAME: CITY OF CARMEL,CARMEL CLAY
PAST DUE CHARGES 502.65 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 1,377.60
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 1 ,377.60
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE.
FOR BILLING QUESTIONS, PLEASE CONTACT YOUR ACCOUNTING SPECIALIST
GEORGIE RUSSO AT 1-860-277-9781 OR EMAIL GRUSSO@TRAVELERS.COM
TRAVELERS PAGE ,
DEDUCTIBLE / SELF-INSURED INVOICE
14TG2033-ZLP 5216X7087 04/28/2017 000520012 05/15/2017 17,662.00
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL
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 PAGE ,
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
12114twM0
14TG2033-ZLP 5216X7087 04/28/2017 000520012 05/15/2017 17,662.00
CURRENT CHARGES
CLAIM#: E2U8101 DATE OF LOSS: 07/25/2014
DESCRIPTION: PROF C-LEY, LARRY J. MD TORT NOTICE ALLEGING CLAIMANT
WAS FALSELY AND
CLAIMANT: LARRY LEY
EXPENSE 6,510.00
CLAIM TOTAL 6,510.00
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 61 .60
CLAIM TOTAL 61.60
CLAIM#: E7DO640 DATE OF LOSS: 06/03/2014
DESCRIPTION: PLAINTIFF IS ALLEGING THAT THE CARMEL PD UNLAWFULLY
PULLED HIM OVER AN
CLAIMANT: JASON MARAMAN
EXPENSE 7, 176.00
CLAIM TOTAL 7, 176.00
PAST DUE CHARGES
CLAIM#: E2U8101 DATE OF LOSS: 07/25/2014
DESCRIPTION: PROF C-LEY, LARRY J. MD TORT NOTICE ALLEGING CLAIMANT
WAS FALSELY AND
CLAIMANT: LARRY LEY Submitted To
EXPENSE 2,097.20
CLAIM TOTAL 2,097.20
MAY 0 8 2017
Clerk Treasurer
TRAVELERS PAGE 2
DEDUCTIBLE / SELF-INSURED INVOICE
i iyriTwim
14T62033-ZLP 521GX7087 04/28/2017 000520012 05/15/2017 17,662.00
PAST DUE CHARGES CONTINUED
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 1,817.20
CLAIM TOTAL 1,817.20
TOTAL CLAIM(S) DUE $17,662.00
ACCOUNT SUMMARY
CURRENT CHARGES 13,747.60 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 3,914.40 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 17,662.00
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 17.662.00
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE.
FOR BILLING QUESTIONS, PLEASE CONTACT YOUR ACCOUNTING SPECIALIST
GEORGIE RUSSO AT 1-860-277-9781 OR EMAIL GRUSSO@TRAVELERS.COM