HomeMy WebLinkAbout204995 12/20/2011 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1
0 ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $10,390.58
CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE
CHICAGO IL 60693 CHECK NUMBER: 204995
CHECK DATE: 12/20/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 000396680 6,577.45 GENERAL INSURANCE
1205 4347500 000396798 28.20 GENERAL INSURANCE
1205 4347500 000397319 3,784.93 GENERAL INSURANCE
TRAVELERS J PAGE 1
DEDUCTIBLE SELF INSURED INVOICE
i i
GP09315757 521GX7087 11/30/2011 000396798 12/15/2011 28.20
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL, CARMEL CLAY PARKS BUILD
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.
TRAVELERS PAGE 1
GP09315757 521GX7087 11/30/2011 000396798 12/15/2011 28.20
CURRENT
CLAIM#: EPS2377 DATE OF LOSS: 02/19/2011
DESCRIPTION: C- PARK,GREG VS CITY OF CARMEL POLICE MERIT BOARD.
COMPLAINT FILED AGAI
CLAIMANT: GREG PARK
EXPENSE 28.20
CLAIM TOTAL 28.20
CURRENT CHARGES $28.20
ACCOUNT SUMMARY
CURRENT CHARGES 28.20 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 28.20
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 28.20
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- 800 356 -4098 EXT. 08900: ANTONIO CONTRERAS
D
DEC 19 2011
By
TRAVELERS
NON- FUNDED DEPARTMENT
ONE TOWER SQUARE -9MN
HARTFORD, CT 06183
39093
CITY OF CARMEL, CARMEL CLAY PARKS BUILD
ONE CIVIC SQUARE
CARMEL IN 46032
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TRAVELERS J PAGE 1
DEDUCTIBLE SELF INSURED INVOICE
•i e
GPO9313908 521GX7087 11/30/2011 000396680 12/15/2011 6,577.45
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL; CARMEL CLAY PARKS
13607 COLLECTIONS CENTER DRIVE ATTN: JIM SPELBRING
CHICAGO, IL 60693 ONE CIVIC SQUARE
CARMEL IN 46032
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS.
PLEASE WRITE THE POLICY ACCOUNT NUMBER ON YOUR CHECK.
AW
TRAVELERS J PAGE 1
GP09313908 5216X7087 11/30/2011 000396680 12/15/2011 6,577.45
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
EXPENSE 155.10
CLAIM TOTAL 155.10
CLAIM CES6844 DATE OF LOSS: 06/13/2010
DESCRIPTION: C ROBERTS, MARY TORT NOTICE ALLEDGING BATTERY,
TRESPASS, FALSE ARR
CLAIMANT: BILLYJOE ROBERTS
EXPENSE 3,038.00
CLAIM TOTAL 3,038.00
CLAIM EMS6617 DATE OF LOSS: 04/16/2010
DESCRIPTION: TORT NOTICE ARISING OUT OF THE ARRE Q
THE CLAIMANT FOR
CLAIMANT: SHARRON ATKINS D
DLL OLL 19 2011 EXPENSE 3,384.35
CLAIM TOTAL 3,384.35
CURRENT CHARGES $6,577.45
ACCOUNT SUMMARY B
CURRENT CHARGES 6,577.45 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 6,577_.45
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 6,577.45
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- 800 356 -4098 EXT. 08900: ANTONIO CONTRERAS
TRAVELERS
NON- FUNDED DEPARTMENT
ONE TOWER SQUARE -9MN
HARTFORD, CT 06183
39094
CITY OF CARMEL; CARMEL CLAY PARKS.
ATTN: JIM SPELBRING
ONE CIVIC SQUARE
CARMEL IN 46032
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TRAVELERS J PAGE 1
DEDUCTIBLE SELF INSURED INVOICE
I qRlll IL ko 0 P] Vi 14 4;M:l I q W I 1 1 I
303GP64A -810 5216X7087 11/30/2011 000397319 12/15/2011 3,784.93
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL,CARMEL CLAY
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.
AMk
TRAVELERS J PAGE 1
•I I I I 1 I
303GP64A -810 521GX7087 11/30/2011 000397319 12/15/2011 3,784.93
CURRENT
CLAIM ESA7023 DATE OF LOSS: 11/01/2011
DESCRIPTION: C JONES, JODI IV DRIVEN BY KEITH FREERWAS SB ON 5R37
WHEN IT STRUCK T
CLAIMANT: JODI L JONES
LOSS 453.08
CLAIM TOTAL 453.08
CLAIM ESA7747 DATE OF LOSS: 11/07/2011
DESCRIPTION: C STIENKE, KEVIN POLICE VEHICLE ATTEMPTED TO PULL
OUT TO THE RIGHT F
CLAIMANT: KEVIN L STIENKE
LOSS 1,197.64
CLAIM TOTAL 1,197.64
CLAIM ESA8715 DATE OF LOSS: 11/1142oll
DESCRIPTION: IV WAS GOING TO MAKE A LEFT HAND TUR REAL/f,�D ITU
WAS A I WAY STREET D
CLAIMANT: JESSICA ADKINS DEC 19 2011
j LOSS 2,134.21
CLAIM TOTAL 2,134.21
B CURRENT CHARGES $3,784.93
ACCOUNT SUMMARY
CURRENT CHARGES 3,784.93 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 3,784.93
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 3
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- 800 356 -4098 EXT. 08900: ANTONIO CONTRERAS
TRAVELERS
NON- FUNDED DEPARTMENT
ONE TOWER SQUARE -9MN
HARTFORD, CT 06183
39092
CITY OF CARMEL,CARMEL CLAY
ONE CIVIC SQUARE
r
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
$0.00
11/30/11 000396798 $28.20
11/30/11 000396680 $6,577.45
11/30/11 000397319 $3,784.93
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 NO. WARRANT N
ALLOWED 20
Travelers
IN SUM OF
13607 Collections Center Drive
Chicage, IL 60693
$10,390.58
ON ACCOUNT OF APPROPRIATION FOR
Administration Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT
Board Members
I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
1205 000396798 43- 475.00 $28.20
materials or services itemized thereon for
1205 000396680 43- 475.00 $6,577.45 which charge is made were ordered and
1205 1 000397319 43- 475.00 $3,784.93 received except
Monday, December 19, 2011
Director, Administration
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund