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HomeMy WebLinkAbout201448 09/13/2011 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1 ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $3,285.30 `4 CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 CHECK NUMBER: 201448 ho„ c CHECK DATE: 9/1312011 DEPARTMENT ACCOUNT PO NUMBER INVOICE N AMOUNT DESCRIPTION 1205 4347500 389055 2,636.70 GENERAL INSURANCE 1205 4347500 389175 648.60 GENERAL INSURANCE TRAVELEIRS J� PAGE 1 DEDUCTIBLE SELF INSURED INVOICE AGENT COPY GPOS313908 521GX7087 08/31/2011 000389055 09/15/2011 2,636.70 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. �A r ELES� PAGE 1 1"l lilrirm ITJ 11 I 1 1 1 I GPO9313908 521GX7087 08/31/2011 000389055 09/15/2011 2,636.70 CURRENT CLAIM CAW7554 DATE OF LOSS: 01/04/2007 DESCRIPTION: C JACKSON, CHAD TORT NOTICE ARISNG OUT OF ALLEGED PC,,* INJURIES THE CLA CLAIMANT: CHAD JACKSON EXPENSE 408.90 CLAIM TOTAL 408.90 CLAIM CES6844 DATE OF LOSS: 06/13/2010 DESCRIPTION: C ROBERTS, MARY TORT NOTICE ALLEDGING BATTERY, P®IIGC TRESPASS, FALSE ARR CLAIMANT: BILLYJOE ROBERTS EXPENSE 1,522.80 CLAIM TOTAL 1,522.80 CLAIM EMS6617 DATE OF LOSS: 04/16/2010 DESCRIPTION: TORT NOTICE ARISING OUT OF THE ARREST MADE BY CPD OF PO I1 L G THE CLAIMANT FOR CLAIMANT: SHARRON ATKINS EXPENSE 705.00 CLAIM TOTAL 705.00 CURRENT CHARGES $2,636.70 ACCOUNT SUMMARY -._2,- 636.70..... INSURED- NAME: -01 -TY OF CARMEL ;CARMEt °CL PARK$ _BUI PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC UNAPPLIED PAYMENTS 0. 00 AGENT PHONE: (317) 817 -5000 TOTAL DUE 2,636,70 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 2,636.70 CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE. FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE HELPOESK @TRAVELERS.COM OR CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1- 800 -356 -4098 EXT. 08900: MIONIO C ERAS dwPib J.N@b9,&H 110z 9 4 d3 SEP 12 2011 ey_�. TRA SELE SJ PAGE 1 DEDUCTIBLE SELF INSURED INVOICE AGENT COPY GPOS315757 5216X7087 08/31/2011 000389175 09/15/2011 648.60 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. TRAVELER� PAGE 1 GP093i5757 5216X7087 08/31/2011 00038917,5 09/15/2011 648.60 CURRENT CLAIM EOG5081 DATE OF LOSS: 05/12/2011 DESCRIPTION: KNONSARI. RANA. CLAIMANT ALLEGES DISCRIMINATION DUE TO Pol,ce MERDISABILITY C CLAIMANT: RANA KHONSARI EXPENSE 648.60 CLAIM TOTAL 648.60 CURRENT CHARGES $648.60 _ACCOUNT SUMMARY CURRENT CHARGES 648.60 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 648.60 DISPUTED ITEMS 0.00 ACC OUNT BALANCE 648.60 CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUE TIONS RELATED TO YOUR POLICY OR COVERAGE. FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE- HELPOESK @TRAVELERS.COM OR CONTACT THE FOLLOWING ACCOUNTING SPECIALIST A 1 -800 -356 -4098 EXT. 08900: ANTONIO CONTRERAS TRAVELERS) PAGE 1 DEDUCTIBLE SELF- INSURED INVOICE AGENT COPY 1 1 1 I 1 1 GP09315757 521GX7087 08/31/2011 0003BS175 09/15/2011 648.60 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. Aftk TRAVELERS J PAGE 1 1 1 UU 11 k 0111 I 1 GP093i5757 5216X7087 08/31/2011 000389175 09/15/2011 648.60 CURRENT CLAIM EOG5061 DATE OF LOSS: 05/12/2011 DESCRIPTION: KNONSARI, RANA; CLAIMANT ALLEGES DISCRIMINATION DUE TO p© �1�B MERDISABILITY C CLAIMANT: RANA KHONSARI EXPENSE 648.60 CLAIM TOTAL 648.60 CURRENT CHARGES $648.60 ACCOUNT SUMMARY CURRENT CHARGES 648.60 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) B17 -5000 TOTAL DUE 64.8.60 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 648.60 CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE. FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE- HELPDESK @TRAVELERS.COM OR CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1- 800 -3S6 -4098 EXT. 08900: ANTONIO CONTRERAS SEP 12 2011 By VOUCHER NO. WARRANT NO. ALLOWED 20 Travelers IN SUM OF 13607 Collections Center Drive Chicage, IL 60693 $3,285.30 ON ACCOUNT OF APPROPRIATION FOR Administration Department PO# I Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members 1205 000389055 43- 475.00 $2,636.70 I hereby certify that the attached invoice (s), or bill(s) is (are) true and correct and that the 1205 000389175 43- 475.00 $648.60 materials or services itemized thereon for which charge is made were ordered and received except Monday, September 12, 2011 f Director, Administratio 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)) 08/31/11 000389055 $2,636.70 08/31/11 000389175 $648.60 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