HomeMy WebLinkAbout192603 12/08/2010 CITY OF CARMEL, INDIANA VENDOR: 358578 Page 1 of 1
0 ONE CIVIC SQUARE STATE FARM AUTO INSURANCE CO CHECK AMOUNT: $19.65
CARMEL, INDIANA 46032 PO BOX 2362
BLOOMINGTON IL 61702 CHECK NUMBER: 192603
CHECK DATE: 12/8/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 19.65 REFUND
Date: 12/01/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federafm# 356000972
ARE. N T
Bill To: EMILY NICHOLSON ICD -9: 7231 7245 5269 E8130
8830 YARDLEY COURT
INDIANAPOLIS, IN 46268
From: 106TH &MICHIGAN
To: ST. VINCENTS HOSPITAL
1
Patient: EMILY NICHOLSON
8830 YARDLEY COURT Insurance
INDIANAPOLIS, IN 46268- 2
Patient No: 201002567
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
$344.65 $364.30 -19.65
CPT
Date Description Charges Credits
09/28/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
09/28/2010 MILEAGE A0425 $19.65
11/29/2010 COMMERCIAL INSURANCE PAYMENT $364.30
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 12/01/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972 q
a
Bill To: EMILY NICHOLSON ICD -9: 7231 7245 5269 E8130
8830 YARDLEY COURT
INDIANAPOLIS, IN 46268
From: 106TH &MICHIGAN
To: ST. VINCENTS HOSPITAL
i
Patient. EMILY NICHOLSON
8830 YARDLEY COURT Insurance
INDIANAPOLIS, IN 46268- 2
Patient No: 201002567
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
$344.65 $344.65 $0.00
CPT
Date Description Charges Credits
09/28/2010 BASIC LIFE SUPP EMERGENCY A0429 $325.00
09/28/2010 MILEAGE A0425 $19.65
11/29/2010 COMMERCIAL INSURANCE PAYMENT $364.30
12/01/2010 REFUND -19.65
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
CLAIM NO 14- 3062 -698 POLICY NO 1654 686 -14 LOSS DATE 09 -28 -2010 PAYMENT NO 1 18 911229 J
Coverage'Description Amount COL Pay Cd DATE 1 1 -20 -2010
MEDICAL PAYMENT $364.30 600 2 AMOUNT 364.30
TIN 14- 356000972
REMARKS 9/2812010
IK MPC INDIANA 18 -501 L025 STATE. FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 911229 J
WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441
COLUMBUS, OH
11 -20 -2010
DATE mm DD YYYY
'CLAIM NO 14 -3062 -698 INSURED NICHOLSON, THOMAS
LOSS DATE 09 -28 -2010 ON BEHALF OF EMILY NICHOLSON
*EXACTLY THREE HUNDRED SIXTY -FOUR AND 30 /100 DOLLARS *364.3'0
pa to the
Order of.. CARMEL FIRE DEPARTMENT.
2 CIVIC SQ p r'
CARMEL IN 46032 -2584. I�„ Ci�I -rVED N 2 Z"
APPROVED BY
17
CLAIM NO 14- 3062 -698 POLICY NO 1654- 686 -14 LOSS DATE 09 -28 -2010 PAYMENT NO 1 18 911229J
[overa e.'Descri tion.. Amount COL Pa' Cd DATE 11 -20 -2010
M PAYMENT $364.30 600 2 AMOUNT 364.30
TIN 14- 356000972
REMARKS 9/28/2010
STATE FARM MUTLIAL I AUTOMOB`I LE ,INSURANCE COMPANY
WEST LAFAYETTE IN
L N JPMORGAN CHASE BANK NA 55 i.544 {441'
MPC INDIANA 18 501 %LOZS
COLUMBUS,
20 2010`
CLAIM NO 14 -3062 69$ INSURED NICHOLSON THOMAS Dare M M D
Loss DAx�:= Pb-28-2010 ON BEHALF c� EMILY. NICHOLSON
*EXACTLY THREE HUNDRED SIXTY -FOUR AND 30/100 DOLLARS
64 3 0
Pav-to the
Order of` CARMEL:FIRE DEPARTMENT
r
'2 I V I C. S Q
CARMEL• IN 46032 -2584
�IW..
AUTHORIZED SIGNATURE.
AUTHOF DSIGNA7URE:
o; our ,_o
044 3r:62529023311°
k 3
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
�7G,'y�. f �/7�•C�'� Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
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
DEC 6 ZOM
k
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund