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Home My WebLink About175652 08/06/2009 CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1 ONE CIVIC SQUARE DON CLEVELAND CHECK AMOUNT: $807.60 ��o CARMEL, INDIANA 46032 141 STONY CREEK OVERLOOK NOBLESVILLE IN 46060 CHECK NUMBER: 175652 CHECK DATE: 8/6/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4347500 08,0109 807.60 GENERAL INSURANCE Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland Aug -09 Donald: Medicare Part B $96.40 Amount due for August 2009 Humana Choice PPO 44.00 Total Don 140.40 Approved by Ron Carter Barbara: Anthem 809.72 Total Monthly 950.12 85% 807.60 Portion paid by City 15% 142.52 Fifth Third Bank Manage Accounts Credit Card Account Activity Page 1 of 1 The things we do for drearns- o Account Balances Account Nicknames Account Activity Welcome, DONALD H CLEVELAND Frida July 31, 2009 Account Activity I Account S I Account Statements Ex Account: Statement Period: Current Statement Posted Transactions Advanced Search: Keyword Posting D ate Tra nsaction D ate Debit Credit Description 07/29/09 07/27/2009 $809.72 ANTHEM BCBS INS PMT IN 866 649 -2034 OH 07/17/09 07/16/2009 $877.36 MAIL PAYMENT BRANCH CINCINNATI OH 07/16/09 07/15/2009 Transactions and other information that appear on this page have occurred since your last statement cycle date. Please sel statement period to review previous account activity. Disclosure /Error Resolution Copyright Vic, 2009 Fifth (bird Bank, Member FDIC, Lf Equal Housing Lender, All Rights Reserved Contact Us Service Center Help I FA Qs I Privacy Security https: /www.53.com/servlet/efsonline/ account history .html ?TransSortCode= DATE,REVE... 7/31/2009 Si necesita ayuda en. espaiiol para enten.der este documento, puede solicitarla sin costo adiciotutl, llamando al ntimero de senicio al cli.ente que aparece al dorso de sit tarjeta de identificacion o en el folleto de inscription. Invoice 057853934 PRIOR BILLING PERIOD COVERAGE FROM 07 /01/2009 THRU 07 /31/2009 e-�n4 u $1,619.44 Payment Receive on 809.72) Ou to d'n Sa i ftce--asmmm 009 .72 CURRENT PERIOD COVERAGE FROM 08 /01/2009 THRU 08/31/2009 Plan Il $809.72 Current Period Total $809. PLEASE PAY THIS AMOUNT ib13BIN)2/1BI3 BIND 00003379 0000572553934 ruvi IlL)lvl ut_ 0 11 u,—v 111— .1 1351 Wm Howard Taft Anthem. 1 0. W Cincinnati, OH 45206 -1775 An in&j—dan 1-- l ffic bloc Gin, aid W., Slucld A-,mli Amh —Bh,, 0— bloc. Slucld is We -d---f thr Amhcn�lnunywc C'ont�anics, luc. �viRc�islrrul nark, BI-C and 131 —Shield Ass-iali —n IDEN "rmCA'r10N 018M62629 071I(y WK2U850 INIM) 3374 UI Due Date: 08- 01 2009 111111111111111111111111 1111 1111111114 11111111111 1111111111111 Billing Date: 07 -10 -2009 #BWNCQXF Coverage Period From: 08 -01 -2009 0 #AIM000000000ODS(WINDI -MB I KY0303A645 Coverage Period Through: 08 31 2009 W Cleveland, Barbara L 141 Stony Creek Overlook Total Amount Due: $1,619.44 Noblesville, IN 46060 -5427 SEE REVERSE SIDE FOR BILLING DETAILS. Questions about your bill or interested in other payment options? Did you know you can make your payment over the phone'? For assistance, please call the Customer Service phone number listed on the back of your Identification Card. Choosing to mail in your payment? Please allow 7 to 10 days to ensure timely processing of your payment. Please remember to list your 9 -digit Identification Dumber on your check, include the lower portion of this page and mail to the address specified. If you have already mailed in Your payment, thank you for your continued membership with us. IMPORTANT NOTICE: If you have received a reminder notice from Anthem Blue Cross and Blue Shield regarding a past due payment, this bill includes all amounts that you owe to keep your policy in force. To avoid any lapse in coverage, the Total Amount Due listed on this bill must be received by the Due Date. Anthem Blue Cross and Blue Shield's issuance of this bill does not waive its contractual right to automatically terminate your coverage for failure to pay premiums in a timely manner. Payments recently mailed may not be reflected. DETACH AND RETURN THIS SECTION WITH YOUR PAYMENT- DO NOT STAPLE MAKE CHECKS PAYABLE TO ANTHEM BLUE CROSS BLUE SHIELD Cleveland, Barba¢a L AND N1_AIL TO THE ADDRESS BELOW Subxriber [D From Date Through Date Due Date 018M62629 08/01/2009 08/31/3009 08/111 /2009 Amount Due Amount Paid $1,619.44 V O 7Z Unit No. 002 INDI -MB I 7 v ��Y'' IIIIIIII 1111III IIIIII IIIIII IIIIII IIIIIIIIIIIIII IIIIIIII IIIII ANTHEM BCBS IN INDIVIDUAL PO Box 105674 Atlanta GA 30348 -5674 1 4001954140000018226262970801200900001619440025 Your 2005 Morith[y Premiums fGr Medricare Part A (Hospital Insurance) Monthly Premium Most people don't pay a Part A premium because they paid Medicare taxes while working. You pay up to $443'( each month if you don't get premium -free Part A. Part B (Medical Insurance) Monthly Premium If Your Yearly Income Is You Pay File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below $96.40' $85,001- $107,000 $170,001- $214,000 $134.90'( $107,001- $160,000 $214,001- $320,000 $192.70' $160,001- $213,000 $320,001 $426,000 $250.50' above $213,000 above $426,000 $308.30'( Note: If you get a monthly benefit payment from Social Security, the RRB, or the Civil Service, you must have your Part B premiums deducted from your monthly benefit payment. If you don't get any of these benefit payments and choose to sign up for Part B, you will get a bill. If you choose to buy Part A, you will always get a bill for your premium. You can mail your premium payments to the Medicare Premium Collection Center, P.O. Box 790355, St. Louis, MO 63179 -0355. If you get a bill from the RRB, mail your premium payments to RRB, Medicare Premium Payments, P.O. Box 9024, St. Louis, MO 63197 -9024. Part W en espanol H UMANA-1 A4ed Ida re Toll -free: 1 800 372 2147 �lu;darwe wlicia y ou „ccd it mwE TTY users: 1 877 833 4486 I U h Print This Pag Y Enlarge Text I L Help Return to Previous Screen Plan Details Humana Choice PPO Plans PPO r R5826 -008 Monthly Plan Premium: $44.00 PI n Premiums for Peo with Extra Help Rx Coverage: Annual Part D Deductible $0.00, Annual Medical D $0. 00 Maximum Medical Out -of- $5,000.00 Pocket: Prescription Drug Coverage: Amount you pay per prescription Type of Drug Stage 1 Stage 2 Stage 3 Stage $0 -$295 $296- Over 4** $2700 $2700 Over $4350 Preferred $7 $7 100% 5% Generic Preferred $40 $40 100% 5% Brand Non Preferred $65 $65 100% 5% Brand Specialty 33% 33% 100% 5% Physician Detail: Option to see physicians in- or out- of the plan's network. No referrals required. You pay more for out -of- network services. Doctor Office Visits: Primary Care Physician: $15.00 Copay Specialist: $35.00 Copay Hospitalization: $800.00 per admit https: /www.humana- medicare. com/ SeniorWizardNET/PlanDetails.aspx 3/27/2009 Prescribed'by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) 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 C lw" Purchase Order No. (f yc Pe Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) ?///o S o di es rls o r�� cr U 2�0 o7 �D Total r� 1 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. ALLOWED 20 IN SUM OF yG Cho ON ACCOUNT OF APPROPRIATION FOR 3 q`7L�:� Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoices or 91 2 0 ?0105 �,FzI7Sa� F07-6o bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except 200,9 Si atur Director o 2pera Title Cost distribution ledger classification if claim paid motor vehicle highway fund