155993 01/24/2008 a CITY OF CARMEL, INDIANA VENDOR: 359957 Page 1 of 1
ONE CIVIC SQUARE BLOCKOMS GOLF MANAGEMENT CO LLLCC CHECK AMOUNT: $452.00
CARMEL, INDIANA 46032 7033 SEA OATS LANE
+ti2pb� o INDIANAPOLIS IN 46250 CHECK NUMBER: 155993
CHECK DATE: 1/24/2008
c�
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
905 4347500 452.00 GENERAL INSURANCE
I
J
WALKER ASSOCIATES INSURANCE January 1Y, 2UU8
PO BOX
AN 19445
OL SILECTIVE
INDIANAPOLIS, IN 46219-&t45
Inttrra>lcc
Phone No. 317- 353 -8000
BLOCKOMS GOLF MANAGEMENT CO LLC DBA
7033 SEA OATS LN
INDIANAPOLIS IN 46250 -4131
loll fit 11111, 111.1. 1111n At fill N ..11 No ll1n1ll1oll1nil1lnlll
REINSTATTMENT NOTICE.
1013
BLOCKOWIS GOLF MANAGEMENT CO.
26.6
DATs dl 7W 375
PAY7*TNE
tpoR 6-eAA-&'VAL 1VL6UVA.4&r
OF
nit now? www.selective.com or cau 1 -aaa-y I4- tI+ctr_
NOTICE If any future installments are WE in this policy term, the full
outstanding balance will be requirM to-reinstate coverage. 'Yo-j can avoid
this action by making installment payments by the due date.
Account Numkr Policy Balance Installment Due Due Bate
843 8763S6 2,712.00 452.00 101-27-2008
Amount Paid
Make Check Payable To:
BLOCKOMS GOLF MANAGEMENT CO LLC DBA Selective Insurance Company of America
7033 SEA OATS LN Box 371468
INDIANAPOLIS IN 462504131 Piusburgh PA 15250 -7468
1.. X11. 1111111 11119INIIis111it1111111111311 31911 1 91 11111 111111
88938763560112200800000452 0000002712 002937370 10803040L030319082720070000b
Please write your account number on your check and send this portion with your payment_ rMank you.
DB5- 07F(06i2002) 00 13040 00000 INSWED COPY
Z d 0866 9VB sulolool4 Ined d8b:Z6 80 t7Z use
Prescribed by State.goard 7 �,ounts 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.
D inn Paye
vC W Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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.
R ACAt mG n ALLOWED 20
1
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
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
d
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund