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HomeMy WebLinkAbout165109 10/29/2008 CITY OF CARMEL, INDIANA VENDOR: 362072 Page 1 of 1 ONE CIVIC SQUARE ACCIDENT FUND INSURANCE CO CARMEL, INDIANA 46032 PO BOX 77000 CHECK AMOUNT: $1,530.00 DEPT 77125 CHECK NUMBER: 165109 DETROIT MI 48277 -0125 CHECK DATE: 10/29/2008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOU DESCRIPTION 1150 4347500 1,530.00 GENERAL INSURANCE r/ t INSURED COPY ccide Fund INSURANCE COMPANY OF AMERICA Invoice Date 09/25/2008 PO BOX 77000 DEPT 77125 DETROIT Ml 48277-0125 ,U L) Insured: Agent: BLOCKOMS GOLF MANAGEMENT CO. WALKER ASSOCIATES INSURANCE LLC PO BOX 19445 12120 BROOKSHIRE PARKWAY INDIANAPOLIS IN 46219 -0445 CARM IN 46033 -9999 f II /1/11/1// ll ll /1111/ llllllllll ll llllll llillllllllllll i`1 Ill lillllllllllllllllllllilll llllilllll #i Ill lll�Illl Policy Number WCV 6033567 00 01 Telephone 317- 353 -8000 Agency Number 0015185 Effective Date: 07/2112007 Expiration Date: 07/21/2008 Audit Type Estimated The audit of your policy has been completed. The final premium, payments and balances are due as follows: Audit Earned Premium: 7,9 NSF /Stop Pay Fees:$ 20.00 Collectable Balance: 7,921.00 Payments Received /Paid: -6,391.00 Total Amount Applied: -6,391.00 I Total Due From Insured:$ 1,530.00 (Includes Prior Balance) Please remit any balance due within 30 days of the above date issued. If you have any questions, call Customer Service 1- 877- 563 4636. DE i iCI ALONG TiiiS P ERFORA T ION r Return this portion with your remittance to ensure proper credit. Policy Number: wcv 6033567 00 01 0015185 Effective Date: 07/21/2007 Amount Due: $1,530.00 Check. Number (Please write cheek number in the space provided) Insured: Please Remit Payment to: BLOCKOMS GOLF MANAGEMENT CO, ACCIDENT FUND a 0 LLC PO BOX 77000 DEPT 77125 12120 BROOKSHIRE PARKWAY 0000000320 DETROIT MI 48277-0125 CARMEL IN 46033 -9999 ll�nllul n ll llll ll l�nl�llnnnl�nlllllllnlnll C9 0000000153000 000000072107 0000000000 AFCWCV00 0101WCV603356700 4 Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL 'l 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 �CCc c /_�-c "Jo Purchase Order No. sUe AJ C c9 Q 6 Ca Terms Date Due Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) ©g o 6 J.76 7 .5-30 Bm Ue� o Total X6 3D 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 O, 7 7orw &2� 77/2-5 153 ON ACCOUNT OF APPROPRIATION FOR Board Members Po# or Ifd;dt31L;E NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or ��So w 335�7 on S®zJ Sp`' 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 20 Signature of Cost distribution ledger classification if Title claim paid motor vehicle highway fund