HomeMy WebLinkAbout195681 03/16/2011 F CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1
ONE CIVIC SQUARE TRAVELERS
CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK AMOUNT: $1,902.55
CHICAGO IL 60693
CHECK NUMBER: 195681
CHECK DATE: 3/16/2011
DEPARTMENT ACCOUNT PO NUMBER INV NUMBER AMO DESCRIPTION
1205 4347500 000373739 28.20 GENERAL INSURANCE
1205 4347500 000374326 1,874.35 GENERAL INSURANCE
TRAVELf RS J PAGE 1
DEDUCTIBLE INVOICE
AGENT COPY
GPO9313908 5216X7087 02/28/2011 000373739 03/15/2011 28.20
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.
TRA 1/ L LER�.7� PAGE 1
1 -mmil 14 MIT-ld .114 wi 11 J)NIMmuummm,
1
GPO9313908 521GX7087 02/28/2011 000373739 03/15/2011 28.20
CURRENT
CLAIM#: CAW7554 DATE OF LOSS: 01/04/2007
DE CRIP�TION: C JACKSON, CHAD TORT NOTICE ARISNG OUT OF ALLEGED
1 I I C INJURIES THE CLA
CLAIMANT: CHAD JACKSON
.EXPENSE 28.20
CLAIM TOTAL 28.20
CURRENT CHARGES $28.20
ACCOUNT SUMMARY
CURRENT CHARGES 28.20 INSURED NAME: CITY OF CARMEL,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 29.20
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 28.20
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE HELPDESK @TRAVELERS,COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1 800 356 -4098 EXT. 08900: ANTONIO CONTRERAS
D
MAR 14 2011
By
T \AVEj ERS J PAGE 1
DEDUCTIBLE INVOICE
AGENT COPY
1 1 1 1 1 I
303GP64A -810 5216X7087 02/28/2011 000374326 03/15/2011 1,874.35
MAIL PAYMENT TO: AGENT:
TRAVELERS HYLANT GROUP INC
13607 COLLECTIONS CENTER DRIVE PO BOX 40925
CHICAGO, IL 60693 INDIANAPOLIS IN 46280 -0825
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS.
PLEASE WRITE THE POLICY ACCOUNT NUMBER ON YOUR CHECK.
TRVELERS /J PAGE 1
2014 Ill ill 1:1 4;=.Tqillll k M k l i 11 I 1 1
3036PG4A -810 521GX7087 02/28/2011 000374326 03/15/2011 1,874.35
CURRENT
CLAIM ENZ3344 DATE OF LOSS: 02/03/2011
DESCRIPTION: C CANO, MAYRA IV BACKING UP WITH TRUCK SNOW PLOW
BLADE STRUCK A PA
CLAIMANT: LUIS CANO
1Dnve.r Kura Kir j LOSS 1,874.35
_1 CLAIM TOTAL 1,874.35
CURRENT CHARGES $1,874.35
ACCOUNT SUMMARY
CURRENT CHARGES 1,874.35 INSURED NAME: CITY OF CARMEL,CARMEL CLAY
PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 5000
TOTAL DUE 1.874.35
DISPUTED ITEMS 0,00
ACCOUNT BALANCE 1,874.35
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE HELPDESK@TRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1- 800 356 -4098 EXT. 08900: ANTONIO CONTRERAS
MAR 14 2011
By
VOUCHER NO. WARRANT NO.
ALLOWED 20
Travelers
IN SUM OF
13607 Collections Center Drive
Chicage, IL 60693
$1,902.55
ON ACCOUNT OF APPROPRIATION FOR
Carmel Administration
PO# 1 Dept. INVOICE NO_ ACCT #!TITLE AMOUNT Board Members
1205 000374326 43- 475.00 $1,874.35 1 hereby certify that the attached invoice(s), or
1205 000373739 43- 475.00 $28.20 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, March 14, 2011
Director, A ministrat n
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))
02/28/11 000374326 $1,874.35
02/28/11 000373739 $28.20
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