HomeMy WebLinkAbout181858 02/03/2010 7 CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1
ONE CIVIC SQUARE DON CLEVELAND
14 o CHECK AMOUNT: $832.25
l,:� CARMEL, INDIANA 46032 141 STONY CREEK OV
'.4,0 o- NOBLESVILLE IN 46060 CHECK NUMBER: 181858
CHECK DATE: 2/3/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4347500 20110 832.25 GENERAL INSURANCE
Monthly Medical Insurance Premiums
Donald H. and Barbara L. Cleveland
Feb -10
Donald:
Medicare Part B $96.40 Amount due for February 2010
Humana Choice PPO 73.00
Total Don 169.40 Approved by Ron Carter
Barbara:
Anthem 809.72
Total Monthly 979.12
85% 832.25 Portion paid by City
15% 146.87
ANTHEM BCBS IN INDIVIDUAL INDI -MB I KY0303A645 000784
1351 Wm Howard Taft
Cincinnati, OH 45206 -1775 em:
Ao i d pernkm 3� anscc u[ me Blue Crave auJ I31ue Sh;dd Associazia,. An h n Blue Cress Bluc. Shield is the rra.le unuc ut
the Amhcul nsurao.c Cou4ua;u, l e. ®ReSismrrd nurLs Bhe Cross anJ Bloc ShidJ Assn;atiuu.
IDENTIFICATION 018M62629
01(1510 W 13L23207 ININD 78-101
Due Date: 02 -01 -2010
11111111111111 IIIII I11IIII II II I,I I II I I II1II I I IIII I I I I Ill Billing Date: 01-10-2010
#BWNCQXF Coverage Period From: 02 -01 -2010
0
#AIM0000000000DSO#INDI -MB I KY0303A645 Coverage Period Through: 02 -28 -2010
Cleveland, Barbara L
141 Stony Creek Overlook 'Total Amount Due: $809.72
Noblesville, IN 46060 -5427
SEE REVERSE SIDE FOR BILLING DETAILS. Questions about your bill or interested in making your
payment over the phone? For assistance, please call the Customer Service phone number listed on the
back of your Identification Card.
Choosing to mail in your payment? Please allow 7 to 10 days to ensure timely processing of your
payment. Please list your 9- digit Identification Number on your check, include the lower portion of
this page and mail to the address specified.
If you pay by check, Anthem Blue Cross and Blue Shield charges a "Non Sufticient Funds" (NSF) fee of
$20 for returned, unpaid checks.
IMPORTANT NOTICE: If you have received a reminder notice from Anthem regarding a past due payment,
this hill includes all amounts that you owe to keep your policy in force. To avoid any lapse in
coverage, the Total Amount Due listed on this bill must be received by the Due Date.
Anthem's issuance of this bill does not waive its contractual right to automatically terminate your
coverage for failure to pay premiums in a timely manner. Payments recently mailed may not be
reflected.
DF i ACH AND THIS SECTION WI'Tli YOUR PAYMENT DO NOT STAPLE
MAKE CHECKS PAYABLE TO ANTHEM BLUE CROSS BLUE SHIELD
Cleveland, Barbara L AND MAIL TO THE ADDRESS BELOW
Subscriber ID From Date Through Date Due Date
018M62629 02/01/2010 02/28/2010 02/01 /2010
Amount Due Amount Paid
$809.72 C5 _72
Unit No. 002 1NI)1 -MB 1
GU v 3 22, 11111111 IIIII, IIIIIIIIIIIIIIIIIIIIIIII
ANTHEM BCBS IN INDIVIDUAL
PO Box 105674
Atlanta GA 30348 -5674
1 46019 54140000018826262170201261000UQ080972UO21
Si necesita a yuda en es/xurot pure ente rider este docunlento, puede solicitarla
sin custo adiciorurl, Ilanrando cal minter° de serricio al cliente clue aparece
al dorso de su tarjeta de identi f cacinn o en el folleto de inscription. lnvoicc 063517490
PRIOR BILLING PERIOD COVERAGE FROM 01/01/2010 THRU 01 /31/2010
Previous Total Due $809.72
Payment. Received on 12/29 /2009 ($809.72)
Outstanding Balance as of 91 -19- 2010 $0 :00
CURRENT PERIOD COVERAGE FROM 02 /01/2010 THRU 02/28/2010
Plan 11 $809.72
Current Period 'Total $809.72
PLEASE PAY THIS AMOUNT $809.72
i1413111ND3/11113 13 IND 00000784_000063517490
I Manage Accounts I Credit Card 1 Account Activity Page 1 of 1
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4iV4iSj/AM'_.VAftA4Wit, C4 f pliq m tiLat,a, eENT
Account Balances Account Nicknames
Account Activity
Welcome, DONALD H CLEVELAND
Thursday, January 28, 2010
Account Activity Account Summary Account Statements Export History
Account:
Statement Period: Current Statement
Posted Transactions (
Advanced Search: A.1 Keyword tinJ
Postino Date Transartion Date D-.bit(+) Credit( Description Action
01/27/10 01/25/2010 $809.72 ANTHEM BCBS INS PMT IN 866-649-2034 01-1
Transactions and other information that appear on this page have occurred since your last statement cycle date. Please select another
statement period to review previous account activity. 1 Disclosure/Error Resolution
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Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
0 0 1 CiPeiP 4o 1 Purchase Order No.
Terms
00645e/7/4 I 1 P 060 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
2 ////O 2 /e /O Fro, -4- i- 2 0/0 /7 R32 .25
2 t
Total k3(2 2a5....
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
D c71-7 CIP li'r'/t7y 1 IN SUM OF
Lf/ .S �0 -7p Cc,
jvah/ 7 /pa, //c/
E
ON ACCOUNT OF APPROPRIATION FOR
1 (397.5 06
Board Members
DEP
PO# T or I hereby NO. ACCT #/TITLE AMOUNT y certif y
that the attached invoice(s), or
9'612 2 /c `/753 C 932 25 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
1111111111I
ig :ature
Director of i4 perations
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund