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HomeMy WebLinkAbout203191 10/25/2011 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1 ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $3,998.03 ti•• /o CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE o+ CHICAGO IL 60693 CHECK NUMBER: 203191 CHECK DATE: 10/25/2011 DEPARTMENT ACCOUNT PO NUMB INVOICE NUMBER AMOUNT DESCRIPTION 1205 4347500 000391601 1,409.90 GENERAL INSURANCE 1205 4347500 000391720 563.36 GENERAL INSURANCE 1205 4347500 000392257 2,024.77 GENERAL INSURANCE Amok TRAVELERS) PAGE 1 DEDUCTIBLE SELF INSURED INVOICE AGENT COPY '1 I 1 ill 1 GPO9313908 5216X7087 09/30/2011 000391601 10/15/2011 1,409.90 MAIL PAYMENT TO: AGENT: TRAVELERS HYLANT GROUP INC 13607 COLLECTIONS CENTER DRIVE PO BOX 40925 CH ICAGO. ILGOG93 INDIANAPOLIS IN 46280-0925 e p I�h 'fro i-NI y,p AH RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS. PLEASE WRITE THE POLICY 8 ACCOUNT NUMBER ON YOUR CHECK. 11oz o S ao TRAVELE1RS J� PAGE 1 1 1 1 1 I 1 GPO9313908 521GX7087 09/30/2011 000391601 10/1S/2011 1,409.90 CURRENT CLAIM#: CAW7554 DATE OF LOSS: 01/0412007 DESCRIPTION: C JACKSON. CHAD TORT NOTICE ARISNG OUT OF ALLEGED P O t 1Ce INJURIES THE CLA CLAIMANT: CHAD JACKSON EXPENSE 28.20 CLAIM TOTAL 28.20 CLAIM#: CES6844 DATE OF LOSS: 06/13/2010 DESCRIPTION: C ROBERTS. MARY TORT NOTICE ALLEDGING BATTERY. Police TRESPASS, FALSE ARR CLAIMANT: BILLYJOE ROBERTS EXPENSE 775.50 CLAIM TOTAL 775.50 CLAIM#: EMSSS17 DATE OF LOSS: 04/16/2010 DESCRIPTION: TORT NOTICE ARISING OUT OF THE ARREST MADE BY CPD OF Pa SIG`s THE CLAIMANT FOR CLAIMANT: SHARRON ATKINS EXPENSE 606.20 CLAIM TOTAL 606.20 CURRENT CHARGES $1,409.90 ACCOUNT SUMMARY CURRENT CHARGES 1,409.90 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 1.408.90 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 1,409.90 CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE. FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE- HELPOESK4 OR CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1- 800 356 -4098 EXT. 06900: ANTONIO CONTRERAS D Q OCT 2 4 2011 BY AW TRAVELERS PAGE DEDUCTIBLE SELF INSURED INVOICE AGENT COPY 1 I I 1 1 1 303GP64A -810 521GX7087 09/30/2011 000392257 10/15/2011 2,024.77 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. TRAVELERS PAGE 1 1 I 1 M ill 1 3036P64A -810 5216X7087 09/30/2011 000392257 10/15/2011 2,024.77 CURRENT CLAIMS`: CES9189 DATE OF LOSS: 09/09/2011 DE R TION: IV ROLLED INTO OV WHILE STOPPED AT STOP SIGN 1, G'e CLAIMANT: ANGELA BERGSTEDT L��i�er. 'Dom Snot LOSS 722.82 CLAIM TOTAL 722.82 CLAIM#: EQRS255 DATE OF LOSS: 08/17/2011 DESCRIPTION: IV DRIVER WAS DISTRACTED AND STRUCK REAR OV1 AND OV1 P olrc, a HIT OV 2 REAR CLAIMANT: MIT£N P DESAI LOSS 1,301.95 CLAIM TOTAL 1,301,95 CURRENT CHARGES $2,024.77 ACCOUNT SUMMARY CURRENT CHARGES 2,024.77 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000 TOTAL DUE 2,024.77 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 2,024.77 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 -3SS -4098 E XT. 08900: ANTONIO CONTRERAS I NIVIAH p Q D 11V L 0 1.00 OCT 2 4 2011 ���IJ� By TRAVELER' J�'' S PAGE 1 DEDUCTIBLE SELF INSURED INVOICE AGENT COPY I 1 I I I k'kM i 1 11 7 114 JT114AMJ I j GPO9315757 5216X7087 09/30/2011 000391720 10/15/2011 563.36 MAIL PAYMENT TO: AGENT: TRAVELERS HYLANT GROUP INC 13607 COLLECTIONS CENTER DRIVE PO BOX 40925 CHICAGO, IL 60693 INDIANAPOLIS IN 46280 -0925 RETURN THTS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS. PLEASE WRITE THE POLICY ACCOUNT NUMBER ON YOUR CHECK. TRAVELERS RS PAGE 1 1 1 I I 10 ima 1 1 iwill. I 1 I I GP09315757 521GX7087 09/30/2011 000391720 10/15/2011 563.36 CURRENT CLAIM#.- EPS23'77 DATE OF LOSS: 02/19/2011 DESCRIPTION: C- PARK,GREG VS CITY OF CARMEL POLICE MERIT BOARD. Police COMPLAINT FILED AGAI CLAIMANT: GREG PARK EXPENSE 224.96 CLAIM TOTAL 224,96 CLAIM EQG5o61 DATE OF LOSS: 05/1212011 DESCRIPTION: KNONSARI, RANA; CLAIMANT ALLEGES DISCRIMINATION DUE TO Poitct MERDISABILITY C CLAIMANT: RANA KHONSARI EXPENSE 338,40 CLAIM TOTAL 338.40 CURRENT CHARGES $563.36 ACCOUNT SUMMARY CURRENT CHARGES 563.36 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILOIN PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000 TOTAL DUE 563.36 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 563.36 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. ANTONIO CONTRERAS OCT 2 4 2011 toy lja ljzl i;ij B VOUCHER NO. WARRANT NO. ALLOWED 20 Travelers IN SUM OF 13607 Collections Center Drive Chicage, IL 60693 $3,998.03 ON ACCOUNT OF APPROPRIATION FOR Administration Department PO Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members 1205 000391601 43- 475.00 $1,409.90 I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the 1205 000392257 43- 475.00 $2,024.77 materials or services itemized thereon for 1205 1 000391720 43- 475.00 $563.36 which charge is made were ordered and received except Monday, October 24,, 22011 .Cl Director, Administration 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)) 09/30/11 000391601 $1,409.90 09/30/11 000392257 $2,024.77 09/30/11 000391720 $563.36 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