166525 12/08/2008 =`�e� CITY OF CARMEL, INDIANA VENDOR: 354565 Page 1 of 1
Q ONE CIVIC SQUARE ST PAUL TRAVELERS CHECK AMOUNT: $363.64
sq`: CARMEL, INDIANA 46032 13607 COLLECTION CENTER
+,.__�o CHICAGO IL 60693 CHECK NUMBER: 166525
r CHECK DATE: 12/9/2008
DEPARTMENT ACCOUNT P O NUMBER INVOICE NUMBER AM DESCRIPTION
1205 4347500 305836582009 363.64 GENERAL INSURANCE
I K, AVb J
DEDUCTIBLE INVOICE
GP09313908 5216X7087 11/26/2008 000305836 12/15/2008 11,372.53
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL
13607 COLLECTIONS CENTER DRIVE ONE CIVIC SQUARE
CHICAGO, IL 60693 CARMEL IN 46032
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS.
PLEASE WRITE THE POLICY ACCOUNT NUMBER ON YOUR CHECK.
AWAk
TRAVELERS J PAGE 1
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
GP09313908 521GX7087 11/'26/2008 000305836 12/15/2008 11,372.53
CURRENT
CLAIM A906415 DATE OF LOSS: 01/09/2006
DESCRIPTION: ON 1/9/2006 DEFENDENT'S TERMINATED PLANTIFF FROM HIS
EMPLOYMENT WITH C
CLAIMANT: JOHN NIKOLOFF
EXPENSE 266.00
CLAIM TOTAL 266.00
CLAIM CES0119 DATE OF LOSS: 01/06/2008
DESCRIPTION: C HOFF, MARGARET. CLMNT WAS FOUND UNRESPONSIVE
CARMEL FIRE DEPT RE
CLAIMANT: MARGARET C HOFF
EXPENSE 843.20
CLAIM TOTAL 843.20
CLAIM FZP0593 DATE OF LOSS: 09/26/2008'
DESCRIPTION: C- STARR, BARBARA IV STRUCK A PARKED UNOCCUPIED VEH
WHILE BACKING OUT Uhi /1
CLAIMANT: CLAIMANT: BARBARA STARR ((///l V' 1
LOSS 97.64
CLAIM TOTAL 97.64
CLAIM FZT0568 DATE OF LOSS: 03/08/2007
DESCRIPTION: C PANKRATZ, JACK INSD OPERATES AFTER SCHOOL PROGRAM
CHERRY TREE E s
CLAIMANT: JACK PANKRATZ
LOSS 5,000.00
CLAIM TOTAL 5,000.00
CURRENT CHARGES $6,206.84
tAUt
I K:�1 V GEC K� J
h
DEDUCTIBLE INVOICE
GP09313908 521GX7087 11/26/2008 000305836 12/15/2008 11,372.53
ACCOUNT SUMMARY
CURRENT CHARGES 6,206.84 INSURED NAME: CITY OF CARMEL
PAST DUE CHARGES 5,165.69 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 11,372.53
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 11 372.53
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE COVERAGE.
FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE HELPDESK @TRAVELERS.COM OR
CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1- 800 356 -4098 EXT. 08900: TONY CONTRERAS
Pre�cri6ed''by 4ate Board of Accounts City Form No. 201 (Rev. 1995)
.T 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
Travelers Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
11/26/08 305836 DOL 0912619008 $266.00
Total
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 Nf22/0& WARRANT NO.
rave er s ALLOWED 20
IN SUM OF
13607 Collections Center Drive
$363.64
ON ACCOUNT OF APPROPRIATION FOR
GENERAL FUND
1205 Administration
Board Members
D INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
1205 00 bill(s) is (are) true and correct and that the
materials or services itemized thereon for
1205 305836 475 $97.64 which charge is made were ordered and
received except
20
r
Sign re
Title
Cost distribution ledger classification If
claim paid motor vehicle highway fund