205127 01/04/2012 CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
ONE CIVIC SQUARE HYLANT GROUP CHECK AMOUNT: $51,422.50
CARMEL, INDIANA 46032 P o BOX 40926
INDIANAPOLIS IN 46082 -4910 CHECK NUMBER: 205127
CHECK DATE: 1/4/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
302 5023990 780348 28,772.50 OTHER EXPENSES
302 5023990 780349 22,650.00 OTHER EXPENSES
s 7 GROUP HYLANT ndi
Indianapolis, 1 146280 -0925 Page, _1
INVOICE# 780349 Local:317 -817 -5000
nCCOU \T.NO
CARME80 79 12/27/11
Workers Coil]
pensatlon
WCX002730
PROD6CER
W. Michael Wells
EFFECTIVE EXPIRATION �L BALANMDUE.ON
City of Carmel 01/01/12 01101113 01/01/12
.�AMOUNT_PAID
Steve Engelking S 22,650.00
One Civic Square
Carmel, IN 46032
Eff.'Date Trri Type Policy 'Descnptionr mount
INVOICE 780319
01/01/12 RIS WC -S WCX002730 TPA Citizens Ins Co of America 22,650.00
WC/TPA INSTALL DUE l /l /12 AND 7/1/12
Invoice Balance: 22,650.00
JAN 4 2012
By
301 Pennsylvania Parkway Suite 201 P.O. Box 40925 Indianapolis, IN 46280 -0925
Toll Free: 800 678 -0361 Local: 317 -817 -5000 Fax: 317- 817 -5151
Risk Management Insurance 40
HYLANT ndia 46280 -0925 e :1
I N V O I C E# 780348
ou
d GROUP
Leal: 317 -s 17 -soaow
ccy :rnom:<��.
CARME80 79 12 /27/11
Workers Compensatloli g
WCX002730
W. Michael Wells
,cEFFECTIVE",.:„ P.'.,,. x., r E\ I', IFL\ T[ OYi., `.�,,,�,„„„_w -DUE 0 N
City of Carmel 01/01/12 01 /01 /13 01/01/12
....a NIOUNTPAID_.._.. NTDUE..,..._. :._..i,«`
Steve Engelking S 28,772,50
One Civic Square
Carmel, IN 46032
#Eff;Date�Trn' T °"ei. Polio �L• E;� Descrlptlon �t�a� j'� �'z �Amount�r
".�uz..���.,��, €sz �s� k ?.w��.t a9^ a�tab Fr�, ��e.. �s. to ";:i?.._�`.��4�i.la.�,��:»"�c. "s'at��� '±.�.Y�`
INVOICE 780348
01/01/12 RIS WC -S WCX002730 WC Citizens ins Co of America 28,772.50
WC/TPA INSTALL DUE 1/1/ 12 AND 7/1/12
Invoice Balance: 28,772.50
E 2012
30lPennsylvania Parkway Suite 201 P.O. Box 40925 Indianapolis, IN 46280 -0925
Toll Free: 800- 678 -0361 Local: 317 -817 -5000 Fax: 317 817 -5151
Risk Management Insurance 40
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
ly'ant Group Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12/27/11 780348 Workers Compensation $28,772.50
'12/2711 1 780349 Workers Compensation $22,650.00
$51,422.50
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.
12/27/11
ALLOWED 20
Hylant Group
IN SUM OF
PO Box 40925
Indianapolis, IN 46280 -0925
$51,422.50
ON-ACCOUNT OF APPROPRIATION FOR
302 Worker's Compensation
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
788348 302 .0
which charge is made were ordered and
780349 302 $22 received except
20
SignaAijrp
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund