HomeMy WebLinkAbout193957 01/19/2011 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1
ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $4,884.13
CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE
CHICAGO IL 60693 CHECK NUMBER: 193957
CHECK DATE: 1!19!2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 368598 4,884.13 GENERAL INSURANCE
AWbk
TRAVELERS J PAGE 1
DEDUCTIBLE INVOICE
AGENT COPY
GP09313908 5216X7087 12/30/2010 000368598 01/15/2011 4,884.13
MAIL PAYMENT T0: AGENT: n
TRAVELERS HYLANT GROUP INC LI
13607 COLLECTIONS CENTER DRIVE PO BOX 40925
CHICAGO, IL 60693 INDIANAPOLIS IN 4628025
JAN 1 7 ZOII
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS.
PLEASE WRITE THE POLICY ACCOUNT NUMBER ON YOUR CHECK. y
e
RAVELERS�� PAGE 1
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
1 I I I 1 I
GPO9313908 5216X7087 12/30/2010 000368598 01/15/2011 4,884.13
CURRENT
CLAIM CAW7554 DATE OF LOSS: 01/04/2007
DESCRIPTION: C JACKSON. CHAD TORT NOTICE ARISNG OUT OF ALLEGED
Po I i c. 6 INJURIES THE CLA
CLAIMANT: CHAD JACKSON
EXPENSE 1,823.50
CLAIM TOTAL 1,823.50
CLAIM EGV3970 DATE OF LOSS: 10/28/2009
DESCRIPTION: IV DRIVER'S SHOE WAS COVERED IN MUD, AND HIS FOOT
SLIPPED OFF THE BRAK Andrew Crept,$
UW41c -5 pY'Ope-r dm (9{ 4 bocia an ur $500. t3(o0.23
CLAIMANT: CAROL HUDSON .J J LOSS 500.00
CLAIM TOTAL 500.00
CLAIM ENJ187S DATE OF LOSS: 11/19/2010
ESCRIPTION: IV BACKED OUT OF PARKING SPACE STRUCK THE CV.
ommunlcafl p,rivec. rYlarlrl►i SEewart
CLAIMANT: TERESA GROSS cpert ct 12H5 SQ f yen{ -W car $Q� 53 3 �i2 '�2
P r 5 LOSS 1.342.42
CLAIM TOTAL 1,342.42
CLAIM ENJ2725 DATE OF LOSS: 11/23/2010
DESCRIPTION: C OAKLEY, ADAM IV TURNED E ONTO PARKVIEW PLACE TO
6 fII'l1-IGS PARK TO DO REPAIR brivc-_ rntcah Bac
CLAIMANT: ADAM OAKLEY PrOpet! L�In �5(o5•
LOSS 565.55
CLAIM TOTAL 585.55
CURRENT CHARGES $4,231.47
JAN 0 6 Zdtl
Adilk TRAVELERS J PAGE 2
DEDUCTIBLE INVOICE
AGENT COPY
'f 1 lll 1 11 1 1 Ij 1 f 1
GPOS313908 521GX7087 12/30/2010 000368598 01/15/2011 4,884.13
ACCOUNT SUMMARY
CURRENT CHARGES 4,231.47 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 652.66 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 4,884.13
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 4,884.13
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE COVERAGE,
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE- HELPDESKPTRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1 -800 -356 -4098 EXT. 08900: ANTONIO CONTRERAS
VOUCHER NO. WARRANT NO.
ALLOWED 20
Travelers
IN SUM OF
13607 Collections Center Drive
Chicage, IL 60693
$4,884,13
ON ACCOUNT OF APPROPRIATION FOR
Carmel Administration
PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1205 I 368598 I 43- 475.00 I $4,884.13 1 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
Tuesday, January 18, 2011
Director, AdmiKistration
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))
01/15/11 I 368598 I $4,884.13
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