HomeMy WebLinkAbout193673 01/19/2011 CITY OF CARMEL, INDIANA VENDOR: 365032 Page 1 of 1
ONE CIVIC SQUARE CHRISTOPHER BURLAK
i
CARMEL, INDIANA 46032 15015 STORY COURT CHECK AMOUNT: $331.55
WESTFIELD IN 46074 CHECK NUMBER: 193673
CHECK DATE: 1/19/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 331.55 REFUND
Date: 01/05/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal tD# 356000972
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Bill To: CHRISTOPHER BURLAK ICD -9: 7231 7245 78701 E8130
15015 STORY CT
WESTFIELD, IN 46074
From: 10101 N MERIDIAN ST
To: CLARIAN HOSPITAL NORTH
ANTHEM BC /BS/ 37010
Patient: CHRISTOPHER BURLAK YRP806M63231
15015 STORY CT Insurance
WESTFIELD, IN 46074- 2
Patient No:
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY, THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$331.55 $663.10 331.55
CPT
Date Description Charges Credits
05/22/2010 BASIC LIFE SDPP- EMERGENCY A0429 $325.00
05/22/2010 MILEAGE A0425 $6.55
09/09/2010 PAYMENT $331.55
12/28/2010 COMMERCIAL INSURANCE PAYMENT $331.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/0512011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
z H Y
a' a a y
Bill To: CHRISTOPHER BURLAK ICD -9: 7231 7245 78701 E8130
15015 STORY CT
WESTFIELD, IN 46074
From: 10101 N MERIDIAN ST
To: CLARIAN HOSPITAL NORTH
ANTHEM BC /BSI 37010
Patient: CHRISTOPHER BURLAK YRP806M63231
15015 STORY CT Insurance
WESTFIELD, IN 46074- 2
Patient No:
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW, THANK YOU,
Total Amount Total Paid Balance
$331.55 $331.55 $0.00
CPT
Date Description Charges Credits
05/22/2010 BASIC LIFE SUFF- EMERGENCY A0429 $325.00
05/22/2010 MILEAGE A0425 $6.55
09/09/2010 PAYMENT $331.55
12/28/2010 COMMERCIAL INSURANCE PAYMENT $331.55
01/05/2011 REFUND 331.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
I V
Return this portion with your payment
Payable To: CARMEL FIRE DEPARTMENT
20100/377 CHRISTOPHER BURLAK RE S U 2010 $331.55
Run Date
05122/2010 Amount Paid
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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CHRISTOPHER BURLAK 20- 667/740 3624
STACEY K. BURLAK
15015 STORY CT
4VESTFIELD, IN 46074 D DTI 1 S Q
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RAY To 71! m- aka. of
DQUARS
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F OU R INDIANA FARM BUREAU INSURANCE@
H P. 0. Box 1250, Indianapolis, Indiana 46206 -1250
UNITED FARM FAMILY MUTUAL INSURANCE
DECEMBER-23, 2010 2415283
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVS
2 CIVIC SQUARE DEC [�j'',
CARMEL IN 46032
POLICY.NUMBER: 5035905 CLAIM REP: 11V CLAIM NO: 7105704
T.I.N.# 356000972
NAME OF INSURED: BURLAK, CHRISTOPHER
DATE OF LOSS: 05 -22 -10 CAUSE CODE: 50 -71
TYPE CLAIM STATUS CODE ITEM NO. AMOUNT PAID
93M PP $331.55
TOTAL PAYMENT $331.55
CARMEL FIRE DEPARTMENT
PAT 4201001377
MED FOR CHRISTOPHER BURLAK; DOS 5/22/10
51�u,�74gR5 5-05
TH &ORIGINAL DOCUMENT I, 45A` REFLECTIVE
ARK ON.THE BACK: HOLD• AT' AN:A- NGLE.TOVIEW.1WHLN. CHECKING THE ENDORSEMENT,
Fifth Third Bank 71 -85
Indianapolis,- Indiana 74
2415283 F IN DIANA FARM BUREAU INSURANCEQ DECEMBER 23 2010
P. O: Box 1250, Indianapolis, Indiana 46206--1250 CLAIM NO 2 3 710 5704
UNITED"FARM FAMILY MUTUAL INSURANCE
$331.55*
To ..the order of: THREE': HUNDRED THIRTY —ONE AND v55 /100 Dollars---------
CARMEL FIRE DEPARTMENT Void After 180 Days
PAT #20.100:1377
MED FOR CHRISTOPHER BURLAK; DOS 5/22/10
See back for
r security features.
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
n 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.
�ff Payee
C�IJ I S40'Dhej- '�91kf IC� Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
se ex� X 33 i. 5.S
h
Total
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
VO R NO. WARRANT NO.
ALLOWED 20
5��Q!'I e- --2urJak IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
,4m ,6 Gc� lrl i'1 /A? k a 1
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
AN 18 2011
d
2
Signature
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund