163579 09/15/2008 CITY OF CARMEL, INDIANA VENDOR: 354565 Page 1 of 1
0 ONE CIVIC SQUARE ST PAUL TRAVELERS
1, CARMEL, INDIANA 46032 13607 COLLECTION CENTER CHECK AMOUNT: $17,620.30
CHICAGO IL 60693 CHECK NUMBER: 163579
ItOH GO
CHECK DATE: 9/15/2008
DEPA RTMENT ACCOUNT P NUMB INVOICE NUMBER AMOUNT DESCRIPTIO
x,1205 4347500 298084 6,768.28 GENERAL INSURANCE
1205 4347500 298276 10,852.02 GENERAL INSURANCE
I
TRAVELERS JW PAGE
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
r r r r r
GPO9311918 0018277244 08/29/2008 000298084 09/15/2008 11,698.29
CURRENT
CLAIM#: CAW2701 DATE OF LOSS: 08/14/2005
DESCRIPTION: LORI MCCANN -CLMT FILED SUIT PAPERS AGAINST INSD /INSD
EMPLOYEES
CLAIMANT: LORI MCCANN
EXPENSE 6,768.28
CLAIM TOTAL 6,768.28
CURRENT CHARGES $6,768.28
ACCOUNT SUMMARY
CURRENT CHARGES 6,768.28 INSURED NAME: CITY OF CARMEL
PAST DUE CHARGES 4,930.01 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 11,698.29
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 11,698.29
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE- HELPDESK @STPAULTRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1- 800 356 -4098 EXT. 08900: JULIE HUPPERT
MC -1GRC
TRAVELERS
385 WASHINGTON STREET
ST PAUL MN 55102 -1396
39675
CITY OF CARMEL
ATTENTION: B COOK
1 CIVIC SQUARE
CARMEL IN 46032
m
m
0
m
0
0
o
N
O
Q
O
N
TRAVELERS PAGE 1
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
GP09313908 5216X7087 08/29/2008 000298276 09/15/2008 16,017.71
CURRENT
CLAIM A9Q6415 DATE OF LOSS: 01/09/2006
DESCRIPTION: ON 1/9/2006 DEFENOENT'S TERMINATED PLANTIFF FROM HIS
EMPLOYMENT WITH C A CLAIMANT: JOHN NIKOLOFF
EXPENSE 1,414.00
CLAIM TOTAL 1,414.00
CLAIM ASY1907 DATE OF LOSS: 01/09/2008
DESCRIPTION: C- CARLTON,LYNN, IV ON A EMERGENCY RUN AND ENTERED THE
INTERSECTION ON
CLAIMANT: LYNN P CARLTON
LOSS 8,756.73
CLAIM TOTAL 8,.756.73
CLAIM CBZ4447 DATE OF LOSS: 07/17/2008
DESCRIPTION: OV WAS PARKED WHEN AN INSD LAWNMOWER PASSED OV AND C
SHOT A LARGE ROCK I�
CLAIMANT: JUNG PARK
LOSS 681.29
CLAIM TOTAL 681.29
CLAIM CBZ4900 DATE OF LOSS: 07/15/2008
DESCRIPTION: C KLITZING, MICHAEL PARKED VEH HAS A CRACKED
WINDSHIELD FROM A MOW
CLAIMANT: DAVID GORIS
LOSS 681.56
CLAIM TOTAL 681.56
CURRENT CHARGES $11,533.58
MC- 1GRC
TRAVELERS
385 WASHINGTON STREET
ST PAUL MN 55102 -1396
38715
CITY OF CARMEL
ONE CIVIC SQUARE
CARMEL IN 46032
N
n
m
ri
D
m
r
m
m
0
D
O
O
Q
O
N
AFARlki
TRAVELERS J PAGE 2
DEDUCTIBLE INVOICE
i
GPO9313908 521GX7087 08/29/2008 000298276 09/15/2008 16,017.71
ACCOUNT SUMMARY
CURRENT CHARGES 11,533.58 INSURED NAME: CITY OF CARMEL
PAST DUE CHARGES 4,484.13 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 16,017.71
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 16,017.71
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE- HELPOESK @STPAULTRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1- 800 356 -4098 EXT. 08900: JULIE HUPPERT
t
t
MC- 1GRC
TRAVELERS
385 WASHINGTON STREET
ST PAUL MN 55102 -1396
38714
CITY OF CARMEL
ONE CIVIC SQUARE
CARMEL IN 46032
m
0
n
0
0
0
a
0
X
Prescr;bed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
Travelers Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
298084 L 08/14/2005
08/29/08
08/29/08 298276 DOL: 07/17/2008
08/29/08 298276 DOL: 01/09/2008 $8,756.73
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 _WARRANT NO.
Paul rave er s ALLOWED 20
13607 Collections Center Drive IN SUM OF
Chicago, IL 60692-
$17,620.30
ON ACCOUNT OF APPROPRIATION FOR
GENERALFUND
1205 Administration
Board Members
P or INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
1205 298084 475 16 8 bill(s) is (are) true and correct and that the
materials or services itemized thereon for
1205 298276 475 $1,414.00 which charge is made were ordered and
1 05 292276 475 received except
1205 298276 475 $8,756.73
20
i
ignatur
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund