HomeMy WebLinkAbout198336 06/15/2011 CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
ONE CIVIC SQUARE HYLANT GROUP
CARMEL, INDIANA 46032 P 0 BOX 40925 CHECK AMOUNT: $25,193.00
INDIANAPOLIS IN 46082 -4910 CHECK NUMBER: 198336
CHECK DATE: 6/15/2011
DEPART A CCOUNT PO NUMBER INVO NUMBER AMOUNT DESCRIPTION
302 5023990 762112 14,056.00 OTHER EXPENSES
302 5023990 762113 11,137.00 OTHER EXPENSES
HYLANT
Indian ax Ii 46280 -0925 a
Local: 317- 817 -5000 I N V O I C E# 762112 Page 1
GROUP
OUfT,LV9!� w,t.:�.�'L,`3'- �3�CSR'
CARMESO 79 I 06/01/11
f
Worl.ers
WCX002730
,m_PRODUCER ='_�i>"
W. Michael Wells
r
.."EroFECTIV E�.'. _x�.,_,,::,..si:;E\PIRATION.M� '8w E DUE ON.,..
City of Carmel 01/01/09 01/01/12 07/10/11
Steve Engelking S 14,056.00
One Civic Square
Carmel, IN 46032
EfF Date Trn.. „Ype.P,ol p .a g3zv A =Descrl tlon dl� y s
E %sr ,r�-. �k,� ��A a p.. �s.�,.t, n�-� t ,`ek, -m ?c ag ?fit INVOICE 4 762112
01 /01 /11 RIS WC -S WCX002730 WC PREM 3 OF 4 Citizens Ins Co of America 14.056.00
Invoice Balance: 14.056.00
301Pennsylvania Parkway Suite 201 P.O. Box 40925 Indianapolis, IN 46280 -0925
Toll Free: 800 678 -0361 Local: 317 817 -5000 Fax: 317 817 -5151
Ri 4 0 1
1 9 JL it IF YLANT ndia 46280 -0925
Local: 317-817-5000 I N V O K E# 762113 g
,®GROUP ?�CCOUPITNO,,_s..x. R._CSIt,o-s
CARME80 79 06/01/11
Wbrl.ers CO►npensatlon�
w,.,.._, ..>,..�:'.sµ....�..,?W`.x.;._._
WCX002730
W. Michael Wells
F. \PIIU \TIOYLx",.xR .F: IM".m..mT3ALANCEAME.ONj x.� �.`4 &,%":i
City of Carmel 01/01/09 01 /01 /12 07/10/11
,r- s ;,r
<.i.AMOUNT, "k D� :xx. ..w....<„<......:...>•.x. i<� s.a,AMOU1T pUE....e..,.B�.s. �..w a...�.�.__ a
Steve Engelking S 11,137.00
One Civic Square
Carmel, IN 46032
r e"` y. �F;.e'^'"�.� I �`#.'r.'R'_°'^ 3•:;,%; 5 ,';.4'�r .�.St, ��`'"i�""; .fix---- r�rs.
t Amount-_
INVOICE 4 762113
01/01/11 RIS WC -S WCX002730 TPA 3 Ol 4 Citizens Ins Co of America 11,137.00
Invoice Balance: 11,137.00
301 Pennsylvania Parkway Suite 201 P.O. Box 40925 Indianapolis, IN 46280 -0925
Toll Free: 800 678 -0361 Local: 317- 817 -5000 Fax: 317- 817 -5151
40
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
Hylant Group
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
06/01/11 762112 WC Prem 3 of 4 14 056.00
06/03/11 762113 TPA 3 of 4 11 137.00
Total 25,193.00
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
VOUCHER NO. WARRANT NO.
Hylant Group ALLOWED 20
IN SUM OF
17475 Jovanna Drive, Suite 1 B
Homewood, IL 60430
$25,193.00
ON ACCOUNT OF APPROPRIATION FOR
302 Workers Compensation
Board Members
Po# or INVOICE NO. ACCT /TITLE AMOUNT I hereby certify hat the attached invoice(s), or
DEPT. y y
bill(s) is (are) true and correct and that the
/62112 302 $14,056.00
materials or services itemized thereon for
762113 302 11,137.00 which charge is made were ordered and
received except
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund