HomeMy WebLinkAbout203647 11/09/2011 CITY OF CARMEN, INDIANA VENDOR: 362876 Page 1 of 1
ONE CIVIC SQUARE TRAVELERS
CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK AMOUNT: $5,438.10
CHICAGO IL 60693 CHECK NUMBER: 203647
CHECK DATE: 11/9/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 394139 5,036.30 GENERAL INSURANCE
1205 4347500 394261 401.80 GENERAL INSURANCE
TRAVELERS J� PAGE 1
DEDUCTIBLE SELF- INSURED INVOICE
AGENT COPY
i i
GPO9315757 521GX7087 10/31/20i1 000394261 11/15/2011 965.16
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
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
•1
GPOS315757 5216X7067 1D/31/2011 000394261 11/15/2011 965.16
CURRENT
CLAIM#: EQGS061 DATE OF LOSS: 05/12/2011
DESCRIPTION: KNONSARI, RANA; CLAIMANT ALLEGES DISCRIMINATION DUE TO
MERDISABILITY C
CLAIMANT: RANA KHONSARI
Po ll ce 0e+* EXPENSE 401.80
CLAIM TOTAL 401.80
CURRENT CHARGES $401.80
ACCOUNT SUMMARY
CURRENT CHARGES 401.80 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 563.36 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0100 AGENT PHONE: (317) 817 -5000
TOTAL DUE 965.16
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 965.16
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- 355 -4098 EXT. 08900: ANTONIO CONTRERAS
D Q D
NOV 7 2011
By
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TRAVELERS PAGE 1
DEDUCTIBLE SELF- INSURED INVOICE
AGENT COPY
firm f I I I 1
GP09313908 5216X7087 10/31/2011 000394139 11/15/2011 6,446.20
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 4 ACCOUNT NUMBER ON YOUR CHECK.
TRAVELERS PAGE 1
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
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GPO9313908 5216X7087 10/31/2011 000394139 11/15/2011 6,446.20
CURRENT
CLAIM CAW7554 DATE OF LOSS: 01/04/2007
DESCRIPTION: C JACKSON, CHAD TORT NOTICE ARISNG OUT OF ALLEGED
INJURIES THE CLA
CLAIMANT: CHAD JACKSON
�ol� EXPENSE 42.30
l CLAIM TOTAL 42.30
CLAIM CESS844 DATE OF LOSS: 06/13/2010
DESCRIPTION: C ROBERTS, MARY TORT NOTICE ALLEDGING BATTERY,
TRESPASS, FALSE ARR
CLAIMANT: BILLYJOE ROBERTS
Po Is cc, EXPENSE 1,092.90
CLAIM TOTAL 1,092.90
CLAIM#: ENS6617 DATE OF LOSS: 04/16/2010
DESCRIPTION: TORT NOTICE ARISING OUT OF THE ARREST MADE BY CPD OF
THE CLAIMANT FOR
CLAIMANT: SHARRON ATKINS
EXPENSE 3,901.10
P O�ICPi CLAIM TOTAL E}1 o
CURRENT CHARGES $5,036.30
no N
D NOV 7 2011
TRAVELERS i PAGE 2
DEDUCTIBLE SELF INSURED INVOICE
AGENT COPY
GPO9313908 521GX7087 10/31/2011 000394139 11/15/2011 6,446.20
ACCOUNT SUMMARY
.CURRENT CHARGES 5,036.30 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS SUILDIN
PAST DUE CHARGES 1,409.90 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 6.446.20
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 6,446.20
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 -600 -356 -4098 EXT. 08900: ANTONIO CONTRERAS
VOUCHER NO. WARRANT NO.
ALLOWED 20
Travelers
IN SUM OF
13607 Collections Center Drive
Chicage, IL 60693
sq -W -lo
ON ACCOUNT OF APPROPRIATION FOR
Administration Department
PO# Dept. INVOICE NO. ACCT #!TITLE AMOUNT
Board Members
1205 000394753 43 475.00 4P
I hereby certify that the attached invoice(s), or
U� ICJ bill(s) is (are) true and correct and that the
1205 000394139 43- 475.00 $6,446.20
materials or services itemized thereon for
1205 I 000394261 I 43 475.00 I $401.80 which charge is made were ordered and
received except
Monday, November 07, 2011
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 N umber (or note attached invoice(s) or bill(s))
10/31/11 000394753 $2,024.77
10/31/11 000394139 $6,446.20
10/31/11 I 000394261 I J $401.80
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