167598 01/07/2009 CITY OF CARMEL, INDIANA VENDOR: 362339 Page 1 of 1
ONE CIVIC SQUARE CITIZENS MANAGEMENT INC CHECK AMOUNT: $25,000.00
CARMEL, INDIANA 46032 PO BOX 620
HOWELL MI 48844 -0620
CHECK NUMBER: 167598
CHECK DATE: 1/7/2009
DE PARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347000 25,000.00 WORKMEN'S COMPENSATIO
Citizens Management Inc.
P. O. Box 620
Howell, MI 48844 -0620
INITIAL LOSS FUND INVOICE
Mr. Steve Engelking, Director of Admin. Date: January 1, 2009
CITY OF CARMEL
One Civic Square
Carmel, IN 46032
Reference: CITY OF CARMEL
Initial Loss Fund billing
Loss Fund Target 25,000.00 Remarks: Initial deposit for Loss Fund account
Funds held at CMI
Service Fee
Amount Due 25,000.00
(See Remarks)
Comments:
Initial deposit for Workers Comp Self- Insured Loss Fund account held at CMI.
Reply: Date:
Total Amount Due: $25,000.00
PLEASE RETURN COPY WITH YOUR PAYMENT
SIW -3 (2 -91)
Page 1 of 1
PAUL BECKER City of Carmel Welcome E -mail
From: ANGELICA CALL
To: PAUL BECKER
Date: 12/8/2008 2:15 PM
Seibject: City of Carmel Welcome E -mail
Gbod Afternoon,
Citizens Management Inc (CMI) welcomes you to Workers Compensation Self Insurance. CMI provides a wide range of services
that will ensure you receive world class customer service at all times. CMI is pleased with our new partnership with CITY OF
CARMEL!
Attached is an invoice for your initial loss fund deposit of $25,000, as well as instructions for wiring the funds to CMI, if that is the
payment method you prefer. These funds will be used to issue claim payments throughout the month and is to be replenished
monthly from a statement that you will receive.
Please contact me if you have any questions regarding this invoice.
We look forward to fulfilling your Customer Service /Accounting needs.
file:HC: \Documents and Settings \Pgb \Local Settings \Temp \GW }00001.HTM 12/9/2008
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
,Citizens Manag Inc Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
01/01/0
25,000.00
Total
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
VOUCHER NO. WARRANT NO.
01/05/G9.
ALLOWED 20
Citizens Ma nagement Inc
IN SUM OF
P.O. Box 620
Howell, MI 48844-0620
$25,000.00
ON ACCOUNT OF APPROPRIATION FOR
GENERAL FUND
1205 Administration
Board Members
PO# or
DEPT. INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
1205 47n 00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
gna Wq
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund