315635 08/30/17 ,tqq
`s CITY OF CARMEL, INDIANA VENDOR: 362876
e ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $*****5,496.36*
?a; CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK NUMBER: 315635
.. CHICAGO IL 60693 CHECK DATE: 08/30/17
'Mj�TON.�p•
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 000524470 4,624.55 GENERAL INSURANCE
1205 4347500 000524471 871.81 GENERAL INSURANCE
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TRAVELERS J� PAGE ,
POLICY NUMBER ACCOUNT NUMBER BILL DATE BILL NUMBER PAYMENT DUE TOTAL OUE'
303GP64A-810 5216X7087 07/31/2017 000524471 08/15/2017 871 .81
CURRENT CHARGES
CLAIM#: EBR9565 DATE OF LOSS: 07/04/2017
DESCRIPTION: BAUTC- WATSON, JERRY IV REAR ENDED OV.
CLAIMANT: JERRY WATSON
LOSS 871 .81
CLAIM TOTAL 871.81
TOTAL CLAIM(S) DUE $871.81
ACCOUNT SUMMARY
CURRENT CHARGES 871 .81 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 871.81
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 871 .81
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
Submlfted To
AUG 15 2017
Clerk Treasurer
TRAVELERS PAGE 1
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
14TG2033-ZLP 521GX7087 07/31/2017 000524470 08/15/2017 4,624.55
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 4, 162.55
CLAIM TOTAL 4,162.55
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 338.80
CLAIM TOTAL 338.80
PAST DUE CHARGES
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 123.20
CLAIM TOTAL 123.20
TOTAL CLAIM(S) DUE Submitted To $4,624.55
AUG 15 2017
Jk
TRAVELERS/ J PAGE 2
DEDUCTIBLE / SELF- INSURED INVOICE
i;POLICY NUMBER ACCOUNT
14TG2033-ZLP 521GX7087 07/31/2017 000524470 08/15/2017 4,624.55
ACCOUNT SUMMARY
CURRENT CHARGES 4,501 .35 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 123.20 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 4,624.55
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 4,624.55
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