165626 11/12/2008 CITY OF CARMEL, INDIANA VENDOR: 354565 Page 1 of 1
ONE CIVIC SQUARE ST PAUL TRAVELERS
CARMEL, INDIANA 46032 13607 COLLECTION CENTER CHECK AMOUNT: $4,589.66
4 CHICAGO IL 60693
CHECK NUMBER: 165626
CHECK DATE: 11/12/2008
DEPARTM ACCOUNT PO NUM INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 303063 2,500.00 GENERAL INSURANCE
1120 4347500 304731 582.80 GENERAL INSURANCE
1205 4347500 304731 1,506.86 GENERAL INSURANCE
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TRAVELERS J� PAGE 1
GPO9311918 0018277244 10/31/2008 000303063 11/15/2008 2,500.00
CURRENT
CLAIM CCL0728 DATE OF LOSS: 08/12/2006
DESCRIPTION: C- LAYNE, MARILYN CLMT ALLEGES SHE WAS A PEDESTRIAN
WAS STRUCK BY A C
CLAIMANT: MARILYN LAYNE
LOSS 2,500.00
CLAIM TOTAL 2,500.00
CURRENT CHARGES $2,500.00
ACCOUNT SUMMARY
CURRENT CHARGES 2,500.00 INSURED NAME: CITY OF CARMEL
PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 2,500.00
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 2,500.00
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
39694
CITY OF CARMEL
ATTENTION: B COOK
1 CIVIC SQUARE
CARMEL IN 46032
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TRAVELERS J� PAGE 1
THIS ACCOUNT IS SCHEDULED TO GO TO A COLLECTION AGENCY
IF PAYMENT IS NOT RECEIVED ON OR BEFORE THE DUE DATE.
GP09313908 5218X7087 10/31/2008 000304734 11/15/2008 7,255.35
CURRENT
CLAIM CES0119 DATE OF LOSS: 01/06/2008
DESCRIPTION: C HOFF, MARGARET. CLMNT WAS FOUND UNRESPONSIVE IV"
CARMEL FIRE DEPT RE
CLAIMANT: MARGARET C HOFF
EXPENSE 582.80
CLAIM TOTAL 582.80
CLAIM CHL9706 DATE OF LOSS: 02/17/2007
DESCRIPTION: IV WAS PLOWING THE INTERSECTION AND IV WAS BACKING UP
AND OV CAME UP B
CLAIMANT: CHRISTOPHER MCMULLEN
LOSS 572.40
CLAIM TOTAL 572.40
CLAIM FZP0593 DATE OF LOSS: 09/26/2008
DESCRIPTION: C- STARR, BARBARA IV STRUCK A PARKED UNOCCUPIED VEH
WHILE BACKING OUT
CLAIMANT: BARBARA STARR
LOSS 934.48
CLAIM TOTAL 934.46
CURRENT CHARGES $2,089.66
MC -1GRC
TRAVELERS
385 WASHINGTON STREET
ST PAUL MN 55102 -1396
38719
CITY OF CARMEL
ONE CIVIC SQUARE
CARMEL IN 46032
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AFM
TRAVELERS J PAGE 2
DEDUCTIBLE INVOICE
GP09313908 5216X7087 10/31/2008 000304734 11/15/2008 7,255.35
ACCOUNT SUMMARY
CURRENT CHARGES 2,089.66 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 7,255.35
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 7,255.35
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
I�
MC -1GRC
TRAVELERS
385 WASHINGTON STREET
ST PAUL MN 55102 -1396
38718
CITY OF CARMEL
ONE CIVIC SQUARE
CARMEL IN 46032
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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
Travelers Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0063 08/12/2006 $2,500.00
10/31/08 3 04731 na 0911719007 $572.40
10/31/08 304731 DOL: 09/26/2008
Total
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER O 10/0$ WARRANT NO.
ALLOWED 20
Coll Center Drive IN SUM OF
Chicago, IL 60693
ON ACCOU�MAP FUND N FOR
1205 Administration
Board Members
PO T°# INVOICE NO. ACCT /TITLE AMOUNT I hereby certify that the attached invoice(s), or
9205 303063 475 2 5QO 0 bill(s) is (are) true and correct and that the
materials or services itemized thereon for
1205 304731 41b 572.40 which charge is made were ordered and
1205 304731 475 02 received except
0 Z 0 4
20
,Signat
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund