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Home My WebLink About205385 01/17/2012 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1 ONE CIVIC SQUARE TRAVELERS CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK AMOUNT: $9,358.84 CHICAGO IL 60693 CHECK NUMBER: 205385 CHECK DATE: 1!1712012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1205 4347500 399107 2,670.65 GENERAL INSURANCE 1205 4347500 399226 42.30 GENERAL INSURANCE 1205 4347500 399786 6,645.89 GENERAL INSURANCE AGM TRAVELERS J PAGE 1 DEDUCTIBLE SELF- INSURED INVOICE l i 3036PG4A -810 521GX7087 12/30/2011 000399788 01/15/2012 6,645.89 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. AIM TRAVELERSJJ PAGE 1 303GP64A -810 521GX7087 12/30/2011 000399788 01/15/2012 6,645.89 CURRENT 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 223.33 CLAIM TOTAL 223.33 CLAIM ESA8715 DATE OF LOSS: 11/11/2011 DESCRIPTION: IV WAS GOING TO MAKE A LEFT HAND TURN REALIZED IT WAS A I WAY STREET CLAIMANT: JESSICA ADKINS LOSS 816.15 CLAIM TOTAL 816.15 CLAIM ESP0008 DATE OF LOSS: 11/21/2011 DESCRIPTION: THE IV WAS NORTHBOUND ON SHADELAND TRIED TO AVOID A Ro1 COLLISION AND SLID cam CLAIMANT: BRANT SENNETT LOSS 5,102.55 CLAIM TOTAL 5,102.55 CLAIM ESP0368 DATE OF LOSS: 11/29/2011 DESCRIPTION: BOTH VEHICLES WERE STOPPED IN TRAFFIC AND THE IV l THOUGHT THE TRAFFIC W CLAIMANT: ROBERT RAMSEY LOSS 503.86 CLAIM TOTAL 503.86 CURRENT CHARGES $6,645.89 D JAN 17 2012 By TRAVELERS NON FUNDED DEPARTMENT ONE TOWER SQUARE -9MN HARTFORD, CT 06183 39107 CITY OF CARMEL,CARMEL CLAY ONE CIVIC SQUARE CARMEL IN 46032 0 0 m 0 0 0 N O a 0 N TRA Y ELC RS J PAGE 2 DEDUCTIBLE SELF INSURED INVOICE di 3036P64A -810 5216X7087 12/30/2011 000399788 01/15/2012 6,645.89 ACCOUNT SUMMARY CURRENT CHARGES 6,645.89 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 6,645.89 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 6,645.89 CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE. FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE- HELPDESK @TRAVELERS.CDM 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 39106 CITY OF CARMEL,CARMEL CLAY ONE CIVIC SQUARE CARMEL IN 46032 O m r r 0 0 0 4 O N 'Aak X25 TRAVFLERs J IZ 5 PAGE 1 DEDUCTIBLE SELF INSURED INVOICE AGENT COPY 1 IWA01 SIP qqllll 1 1 I w i lill GP09313908 521GX7087 12/30/2011 000399107 01/15/2012 2,670.65 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. T!l Q M ELL. RSJ PAGE 1 GP09313908 5216X7087 12/30/2011 000399107 01/15/2012 2,670.65 CURRENT CLAIM CAW7554 DATE OF LOSS: 01/0412007 DESCRIPTION: C JACKSON, CHAD TORT NOTICE ARISNG OUT OF ALLEGED �Q11 Ge INJURIES THE CLA CLAIMANT: CHAD JACKSON EXPENSE 14.10 CLAIM TOTAL 14.10 CLAIM CES6844 DATE OF LOSS: 06/13/2010 DESCRIPTION: C ROBERTS, MARY TORT NOTICE ALLEDGING BATTERY, PC C� TRESPASS, FALSE ARR l CLAIMANT: BILLYJOE ROBERTS EXPENSE 380.30 CLAIM TOTAL 380.30 CLAIM EMS6617 DATE OF LOSS: 04/15/2010 DESCRIPTION: TORT NOTICE ARISING OUT OF THE ARREST MADE BY CPO OF THE CLAIMANT FOR CLAIMANT: SHARRON ATKINS EXPENSE 1,091.85 CLAIM TOTAL 1,091.85 CLAIM ESAS198 DATE OF LOSS: 09/08/2009 DESCRIPTION: CLAIMANT ALLEGES HIS RIGHTS WERE VIOLATED BY MEMBERS po 1IC& OF CARMEL POLICE CLAIMANT: DENNIS W CARLYLE EXPENSE 1,184.40 CLAIM TOTAL 1,184.40 D Lr--\-N CURRENT CHARGES $2,670.55 ,SAN 1 7 2012 1 By i Aftk TRAVELERS J PAGE 2 DEDUCTIBLE SELF INSURED INVOICE AGENT COPY 'I 141 *1 1 fi l imi l illiTi 1 5 14 I 1 I GPO9313908 5216X7087 12/30/2011 000399107 01/15/2012 2,670.65 ACCOUNT SUMMARY CURRENT CHARGES 2,670.65 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 2.670 -65 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 2,670.65 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 RAVED JAN Or 2 I RAVELEdRS JJ PAGE 1 DEDUCTIBLE SELF INSURED INVOICE 1 GPO9315757 5216X7087 12/30/2011 000399226 01/15/2012 42.30 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. TRAVELEIRS J PAGE 1 it k GPO9315757 5216X7087 12/30/2011 000399226 01/15/2012 42.30 CURRENT CLAIM EQG5661 DATE OF LOSS: 05/12/2011 DESCRIPTION: KNONSARI, RANA; CLAIMANT ALLEGES DISCRIMINATION DUE TO MERDISABILITY C CLAIMANT: RANA KHONSARI EXPENSE 42.30 CLAIM TOTAL 42.30 CURRENT CHARGES $42.30 ACCOUNT SUMMARY CURRENT CHARGES 42.30 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN PAST DUE CHARGES 0.00 AGENT NAME: HYLANT GROUP INC UNAPPLIEO PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000 TOTAL DUE 42.30 DISPUTED ITEMS 0.00 ACCOUNT BALANCE 42.30 CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR COVERAGE. FOR BILLING QUESTIONS, PLEASE EMAIL DEDUCTIBLE- HELPDESKC&TRAVELERS.COM OR CONTACT THE FOLLOWING ACCOUNTING SPECIALIST AT 1- 800 356 -4098 EXT. 08900: ANTONIO CONTRERAS D Q Q JAN 17 2012 By TRAVELERS NON FUNDED DEPARTMENT ONE TOWER SQUARE -9MN HARTFORD, CT o6183 39108 CITY OF CARMEL, CARMEL CLAY PARKS BUILD ONE CIVIC SQUARE CARMEL IN 46032 m P N P O O O O a 0 0 VOUCHER NO. WARRANT NO. ALLOWED 20 Travelers IN SUM OF 13607 Collections Center Drive Chicage, IL 60693 $9,358.84 ON ACCOUNT OF APPROPRIATION FOR Administration Department RO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members P "Of Year I hereby certify that the attached invoice(s), or 1205 000399788 43- 475.00 $6,645.89 Prior Year bill(s) is (are) true and correct and that the 1205 000399107 43- 475.00 $2,670.65 Priar Year materials or services itemized thereon for 1205 f 000399226 I 43- 475.00 I $42.30 which charge is made were ordered and received except Friday, January 13, 2012 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 Number (or note attached invoice(s) or bill(s)) 12/30/11 000399788 $6,645.89 12/30/11 000399107 $2,670.65 12/30/11 000399226 I I $42.30 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