HomeMy WebLinkAbout193238 12/22/2010 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of
ONE CIVIC SQUARE TRAVELERS
CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK AMOUNT: $652.66
CHICAGO IL 60693 CHECK NUMBER: 193238
CHECK DATE: 12/2212010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 000366009 652.66 GENERAL, INSURANCE
TRAVELERS J D PAGE 1
!1" �_1 LL ff
DEDUCTIBLE INVOICE 2 Q 2010
AGENT COPY By
1
1 1 1
GPOS313908 5216X7087 11/30/2010 000366009 12/15/2010 652.66
MAIL PAYMENT TO: AGENT:
TRAVELERS HYLANT GROUP INC
13607 COLLECTIONS CENTER DRIVE PO BOX 40925
CHICAGO, IL 60693 INDIANAPOLIS IN 46280 -0925
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS.
PLEASE WRITE THE POLICY ACCOUNT NUMBER ON YOUR CHECK.
RAVELERSJ PAGE 1
1 1 m u. j i m ilig 1 I r
GPO9313908 5216X7087 11/30/2010 000366009 12/15/2010 652.66
CURRENT
CLAIM#: CAW7554 DATE OF LOSS: 01/04/2007
DESCRIPTION: C JACKSON, CHAO TORT NOTICE ARISNG OUT OF ALLEGED
(Do I I C,✓ INJURIES THE CLA
CLAIMANT: CHAD JACKSON
EXPENSE 174.20
CLAIM TOTAL 174.20
CLAIM EJN0833 DATE OF LOSS: 10/13/2010
DESCRIPTION: C SURATI, VIRAL TORT ALLEGING THAT WHILE THh CITY
WAS REPAIRING A siAK hole, 6LL4` E°je_e_'ric �er-,e
CLAIMANT: VIRAL SURATI
LOSS 98.46
CLAIM TOTAL 98.46
CLAIM ELY8178 DATE OF LOSS: 08/20/2010
DESCRIPTION: C -GRAY, TIM. IV BACKING UP AND STRUCK A 6X6 WOODEN
ull �1�185 POST BREAKING IT n 0 F ver-- Dan pe- ar'rrian
CLAIMANT: TIM GRAY
LOSS 380.00
CLAIM TOTAL 380.00
CURRENT CHARGES $652.66
ACCOUNT SUMMARY
CURRENT CHARGES 652.66 INSURED NAME: CITY OF CARMFL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 652,66
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 652.66
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE HELPOESK@TRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1 800- 355 -4098 EXT. 08900: ANTONIO CONTRERAS
1ri n
DEC
I
y
VOUCHER NO. WARRANT NO.
ALLOWED 20
Travelers
IN SUM OF
13607 Collections Center Drive
Chicage, IL 60693
$652.66
ON ACCOUNT OF APPROPRIATION FOR
Carmel Administration
PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1205 I 000366009 I 43- 475.00 I $652.66 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
Monday, December 20, 2010
Director, Ad inistration
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12/15/10 000366009 $652.66
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