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