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Home My WebLink About190484 09/29/2010 CITY OF CARMEL, INDIANA VENDOR: 358578 Page 1 of 1 0 j• ONE CIVIC SQUARE STATE FARM AUTO INSURANCE CO CHECK AMOUNT: $32.75 CARMEL, INDIANA 46032 PO BOX 2362 BLOOMINGTON IL 61702 CHECK NUMBER: 190484 CHECK DATE: 9/29/2010 DE PARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 32.75 REFUND CLAIM NO 14 -3050 -537 POLICY NO 0621- 224 -14E LOSS DATE 07 -29 -2010 PAYMENT NO 1 18 508075 J DATE 09 -09 -2010 Coverage Description Amount COL: P.a 'Cd>s MEDICAL PAYMENT $390.50 600 2 AMOUNT $390.50 TIN 14- 356000972 RECEIVED stP l REMARKS 7/29/2010 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 508075 J WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441 "�o MPC INDIANA 18 -501 L025 COLUMBUS, OH 09-09-2010 DATE MM DD YYYY CLAIM NO 14- 3050 -537 INSURED PATTERSON, SANDRA LOSS DATE 07 -29 -2010 ON BEHALF OF DENISE SATTERWHITE *EXACTLY THREE HUNDRED NINETY AND 50/ DOLLARS *3990 57 G'. Pay to the Orderof CARMEL FIRE DEPARTMENT 2 CIVIC SO CARMEL IN 46032 -2584 APPROVED BY f CLAIM NO 14 -3050 -537 POLICY NO 0621- 224 -14E LOSS DATE 07 -29 -2010 PAYMENT NO 1 18 508075 J Coverage Description. Amount COL Pay Cdl DATE 09 -09 -2010 MEDICAL PAYMENT $390.50 600 2 AMOUNT $390.50 TIN 14- 356000972 N REMARKS 7/29/2010 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 1$ 508075 I WE5T LAFAYETTE IN JPh10RGAN CHASE BANK,, NA 56 1544/441 CDLUMBUS,-OH MPC., INDIANA 1$ 50.1 :U25 09 09 2070 DATE —`M;M D D --Y Y Y Y CLAIM NO 1473050 -537 INSURED PATTERSON, SANDRA LOSS DATE` 07 -29 -2010 ON' BEHALF OF. DENISE SATTERWHITE EXACTLY ie�c *ilr it EXAGTLY THREE HUNDRED NINETY AND 50!100 DOLLARS 390.5 "0: Pay to the Order of: CARMEL FIRE DEPARTMENT 2 CIVIC SQ CARMEL IN 46032 -2584 pi r, P AUTHORIZED SIGNATURE AUTHO D SIGNATURE aw -3on •i 11 'b8b7501307511 1:0', L51, 31:52F�29023DO STATE FARM n EXPLANATION OF REVIEW This is not a bill INSURANCE O r State Farm Mutual Automobile CLAIM NUMBER 14 -3050 -537 OFFICE NAME Insurance Company Indiana MPC Office DENISE SATTERWHITE CARMEL FIRE DEPARTMENT 5819 IVY KNOLL COURT 2 CIVIC SQ Indianapolis, IN 46250 CARMEL, IN 46032 -2584 DATE OF LOSS 7/29/2010 CLAIM HANDLER Unit XC Processor NAME INSURED PATTERSON, SANDRA ADDRESS PO Box 2362 Bloomington, IL. 61702 POLICY NUMBER 062122414 PHONE 866 648 -0715 JURISDICTION Indiana TIN 3 56 -00 -0972 Z IP OF SERVICE 46032 -2584 BILL REFERENCE NA DATE RECEIVED 9/3/2010 NUMBER 729.5 PAIN IN SOFT TISSUES OF LIMB, E813.1 MOTOR VEHICLE COLLISION DIAGNOSIS CODES WITH OTHER VEHICLE, INJURING PASSENGER IN MOTOR VEHICLE OTHER THAN MOTORCYCLE, 959.3 INJURY, OTHER AND UNSPECIFIED, ELBOW, FOREARM, AND WRIST DRAFT NUMBER 11118508075J LINE DATE OF POS CPTIHCPCS MOD/TS UNITS SUBMITTED APPROVED REASON SERVICE AMOUNT AMOUNT CODES 1 7/29/2010 11 A0429 1 325.00 325.00 7/29/2010 2 7/29/2010 7/29/2010 11 A0425 5 32.75 32.75 3 7/29/2010 11 A0429 1 325.00 0.00 99 7/29/2010 4 7/29/2010 11 A0425 5 32.75 32,75 7/29/2010 TOTAL SUBMITTED CHARGES 715.50 TOTAL APPROVED AMOUNT 390.50 MOUNT NOT PAYABLE 0.00 DEDUCTIBLE 0.00 PPORTIONMENT /PRO RATA 0 00 PAID AMOUNT 390.50 Date: 09/15/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD4 356000972 c Bill To: DENISE SATTERWHITE ICD -9: 9593 7295 E8131 5819 IVY KNOLL CT INDIANAPOLIS, IN 46250 From: 96YH &HAGUE RD To: COMMUNITY HOSPITAL -NORTH 1 Patient: DENISE SATTERWHITE 5819 IVY KNOLL CT Insurance INDIANAPOLIS, IN 46250- 2 Patient No: 201002034 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $357.75 $390.50 -32.75 CPT Date Description Charges Credits 07/29/2010 BASIC LIFE SUPP— EMERGENCY A0429 $325.00 07/29/2010 MILE??GE A0425 $32.75 09/14/201.0 COMMERCIAL INSURANCE PAYMENT $390.50 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 09/1512010 CARK0EL FIRE DEPARTMENT EMERGENCY VIED SVCS 2 CIVIC SQUARE CARMEL.|N 40032' (317)571-2805 peuem/uD# 356000972 j Bill To: DENISE SATTERyVH|TE 581S IVY KNOLL CT INDIANAPOLIS, IN 46250 To: COMMUNITY HOSPITAL-NORTH Patient: DENISE SATTERVVH|TE 5819 IVY KNOLL CT Insurance INDIANAPOLIS, IN 46250' Patient No: 201002034 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU Total Amount Total Paid nBalance CPT Date Description Charges Credit� 07/29/2010 B8SZC LIFE SUPP-EMERGENCY A0429 $325-00 07/29/3010 MILEAGE 80425 $32.75 09/l4/20I0 COMMERCIAL INSURANCE e*,MuwT $390.5O 09/15/3010 REFUND S-32.75 APPROVED eY THE STATE BOARD OF ACCOUNTS FOR CITY O+cAnMsL.1sps Prescribed by Stale Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 261 (Rev. 1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by wh +.m, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee J TGE;tE' ctj Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total '#3j. 7- 1 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 IN SUM OF 9J, 7 .2 7 ON ACCOUNT OF APPROPRIATION FOR 1 ltoe U Board Members PO# or INVOICE NO. ACCT /TITLE AMOUNT DEPT. 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 SEP 2 7 2010 s 0 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund