334443 01/18/19 +pr Cqq�
CITY OF CARMEL, INDIANA VENDOR: L2348
t� ONE CIVIC SQUARE UNUM LIFE INSURANCE CO OF AMERICRHECK AMOUNT: $"'''••472.34•
s a CARMEL, INDIANA 46032 PO Box 406946 CHECK NUMBER: 334443
ATLANTA GA 30384-6946 CHECK BATE: 01/18/19
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4358400 REIMB 267.11 REFUNDS AWARDS & INDE
1091 4358400 REIMB 205.23 REF S AWARDS & INDE
. . . " . . . . . . . . . : . ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
VOUCHER NO. WARRANT NO.
An invoice of bill to be properly itemized must show;kind of service;where performed,dates service rendered,by. .
Vendor# Allowed. 20 whom rates per day,number of hours,rate per hour;.number of'units,•prlce'per unit,etc.
Unum Life Insurance Company of America Payee
PO Box 4.06946
aT nta;GA-3038-�6946 In Sum off$ purchaeOr er
. . . . . . . .
lJnum:Life Insurance,Company of America. Terms:
$. .
PO Boi 406R4Q: , .Date Due
:472:34
_ °Atlanta,GA .30384 6946
ON ACCOUNT OF APPROPRIATION FOR
168-ESE/109 Monon Center
'PO#or ' INVOICE NO. ACCT#IfITLE AMOUNT riVOICe DescriptionDept# Invoice.Date ' ` .Number. (or note attached.invoice(s)of bill(s))- PO#' Amount
- - _ - Reim or.Check Refundsent to.us in
1081-99 Reimb 4358400 : $: .267.11 Board Members 1/8/19 Reimb. Aug'18,duplicated refund $ 267.11. =
. . . . . . . . . . . Heimb for Check Refundsentao us In. .
1691 Reimb 4358400: .$ 205.23 ' 1/8/19. Reimb: Aug'18,duplicated refund $ 265.23
I'hereby certify that the attached invoice(s),'or
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. . . .
$ 472.34 Total. '.$. : 472.34 .
January 9,2019 : • . . . . . . . . .
Thereby certify that the attached invoice(s),of bill(s)is'(are)true and correct and l have audited same in'accerdance
With IC 5-11-1.0-1.6
Cost distribution,ledger classification if:
claim paid motor vehicle highway fund signature.: 20
Accounts Payable.Coordinator. — .Clerk-Treasurer. . .
Title
Carmel e Clay
Parks&Recreation CHECK REQUEST
Date:_ Jan.8,20A(4 12A2
Check payable to:
Name: Unum Life Insurance Company of America
Address: PO Box 406946
City,State,Zip Atlanta,GA 30384-6946
Mail check to payee TXXX '=< Return cee c#o.reguestor
(C�P Rj _
I
Check Amount:$ 472.34 Date Required: ASAP
Purpose of Check: Reimburse Unum Life Insurance for check refund sent to us in Au>?ust 2018.
Unum also applied an account credit for this amount. This is to refund the overpayment
Supporting documentation or invoice(s)MUST be attached.
To be paid from:
PO#(if applicable) N/A
Budget account-GL# _ $267.11 from 1081-99-4358400 BAS Admin-Refunds
$205.23 from 1091-4358400 MCC Admin-Refunds
Requested by(print): Audrey Kostrzeewa l
Requested by(signature/date): � ` *11
1,/ 6
Approved by(print): 's
Approved by(signature/date) I q 119
Form recreated 3/10/1b(Business Services)
1/8/2019 Unum.com
Premium Statement
n u
Billing Name: CAItMEL CLAY-, PARKS AND RECREATION
-A _
Billing Number: 0566096-002 8
Due Date: 1)1/2019
Statement Date: 1/3/2019
Coverage Information Amount
Life Monthly Rate: $0.145 per$1000 $179.80
Covered Lives: 62 Coverage Amount: 1,240,000 Back Charge: $0.00
AD&D Monthly Rate: $0.040 per$1000 $49.60
Covered Lives: 62 Coverage Amount: 1,240,000 Back Charge: $0.00
Short Term Disability Monthly Rate: $0.150 per$10 $514.82
Covered Lives: 62 Coverage Amount: 34,321 Back Charge: $0.00
Current Period Amount: $.744_:22 i
Net Adjustment from Prior Statement: -__
Total Amount Due: (,$121G56
Payment Instructions:
1. Payment must be received on or before 1/1/2019.
2.This Billing Number is set-up with the Online Authorization feature. Please use the Online
Authorization service to make a payment.
Billing Period:
1/1/2019-1/31/2019
PC
M6-12400 02 B
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