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Home My WebLink About175793 08/06/2009 CITY OF CARMEL, INDIANA VENDOR: 360618 Page 1 of 1 ONE CIVIC SQUARE STEPHANIE MARSHALL CARMEL, INDIANA 46032 578 TULIP POPPLUR CREST CHECK AMOUNT: $199.11 CARMEL IN 46033 CHECK NUMBER: 175793 CHECK DATE: 8!612009 DEPARTMENT AC COUNT PO NUMBER INVOICE NUMBE AMOUNT DES CRIPTION 902 4347500 060109 199.11 GENERAL INSURANCE Richand Marshall; Jr. SVP Worldwide COBRA Coupon #2 June /2009 Coverage Tier Period Premium BCBS HDHP /HSA Medical Plan Employee Family 06101/2009 06/30/2009 310.68 Delta Dental Plan Employee Family 06/0112009 06/30/2009 22.71 Comments/Notes: Subtotal: $333.39 r I .00 Hi IUUni 'd U �U Return this Coupon and Your Payment to: Coverage for: Total Due: $333.39 Medcom Richard Marshall, Jr. Due Date: 06/01/2009 P.O. Box 10269 Total Enclosed; Jacksonville, FL 32247 -0269 578 Tulip Poplar Crest Carmel, IN 46033 Make Check Payable to: Medcom "_7 r:.`1rIU �.I_j�rp and 1?M. .p ✓76ir_P�Vr7jpn L SVP Worldwide ARRA \btice COBRA PREMIUM REDUCTION COMPUTATION FORM Important Information for Assistance Eligible Individuals who have elected the Premium Reduction: Your premium for coverage periods beginning prior to February 17, 2009 will be at the Full Premium Rate. For coverage periods beginning on or after February 17. 2009, premiums will be calculated at the Premium Assistance Rate until you are no longer eligible for the reduced premium. BCBS HDHP/HSA Medical Plan Reduced Tier Rates: j, 4. J i R_f., Employee Only mployee +Family I a `^1 IV .7 125.70 13 0 Delta Dental Plan Reduced Tier Rates: Sl{ i- Employee Only mployee Family 7.91 z 22.72 Page 7 of 7 f i Certificate of Coverage SVP Worldwide This Certificate of Coverage is intended as proof of prior coverage under our health plan(s) coverage. This Certificate is provided to: Richard Marshall, Jr., Stephanie Marshall, Bret Marshall For more information, please contact: Medcom P.O. Box 10269 Jacksonville, Fl- 32247 -0269 Phone: (800) 523 -7542 This document certifies that the persons fisted below there covered under the named plan(s) listed for the time periods shown. BOBS W)HP /RSA Medical Plan Richard Marshall, Jr. Effective: 01/01/2009 Terminated: 05/02/2009 Stephanie Marshall Effective: 01/01/2009 'Terminated: 05/02/2009 Bret Marshall Effective: 01/01/2009 Terminated: 05/02/2009 Delta Dental Plan Richard Marshall, Jr. Effective: 01/01/2009 Terminated: 05/02/2009 Stephanie Marshall Effective: 01/01/2009 Terminated: 05/02/2009 Bret Marshall Effective: 01/01/2009 Terminated: 05/02/2009 Statement of 111PAA Portability Rights I MPORTANT KEEP THIS CERTIFICATE. This certificate is evidence of vour coverage under this plan. Under a federal hnov:n a., \,)1; duty nec Jdcnec of :ro;rr covcra.ec to re dt:ec e::isiir�� condition cxclrrssl;t� period under another plan,, to help you get special curothnent in another plan, or to pet certain types of individual health coverage even if you have health problems. Preexisting condition exclusions Some grouli health plans restrict coverage for medical conditions present before an individual's enrollment. These restrictions are known as "preexisting condition exclusions." A preexisting condition exclusion can apply only to conditions for which medical advice. diagnosis, care, or treatment was recommended or received within the 6 months before your "enrollment date." )'our enrollment date is your first day of coverage under the plan, or, if there is a waiting period, the first day of }'our waiting period (typically, your first day of work). In addition, a preexisting condition exclusion cannot last for rnore than 12 months after your enruihnem date (18 months if you are a late enrollee). Finally, it preexisting condition exctusion cannot apply to pregnancy and cannot apply to a child who is enrolled in health coverage within 30 days after birth, adoption, or placement for adoption. It' a plan imposes a preexisting condition exclusion, the length of the exclusion must be reduced by the amount of your prior creditable coverage. Most health coverage is creditable coverage, including group health plan coverage, COBRA continuation coverage. coverage under an individual health policy, Medicare, Medicaid, State Children's Health Insurance Program (SCI-IIP), and coverage through high -risk pools and the Peace Corps. Not all forms of creditable coverage are required to provide certificates like this one. If you do not receive a certificate for past coverage. talk to your new plan administrator. You can add up any creditable coverage you have, including the coverage shown on this certificate. However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a plan may not have to count the coverage you had before the break. Therefore. once your coverage ends. you should try to obtain alternative coverage as soon as possible to avoid a 63 -day break. You may use this certificate as evidence of your creditable coverage to reduce the length of any preexisting condition exclusion if you enroll in another plan. Rizht to special enrollment in another plan Under HIPAA, if you lose your group health plan coverage, you may be able to get into another eroup health plan for which you are eligible (such as a spouse's plan) even if the plan generally does not accept late enrollees, if you request enrollment within 30 days (Additional special enrollment rights are triggered by marriage. 0 v f C9 At- vv c. FIN12 —MB Anthem Blue Cross and Blue Shield 1351 William Howard Taft Road r 1 Cincinnati, OH 45206 1775 h/S l�� (..i Lock'sri IMPORTANT BENEFIT INFORMATION ENCLOSED 4� rct- VIII III VIII III�I VIII IfII III 51756 002875' ill Illllllllllllllllllll Illllllllllllillll III Bret L Marshall 257 ARBOR DRIVE CARMEL IN 46032 Anth V' YOUR (,ARI) 1IAS A NE"IV LOOK! N1CC1 your nC,w nlculhcr 11) God. II has :h Il,rnh look and ]:1youl. I I yOU're ahcudy a nlemher and have an old card_ Cool worry. [his one works the samc..lust present it when visiting your pruVideh. It you are an Anthem I;;IUe Cross and 131Uc Shield Health member: we eueoul :lge you to dloos a Nautry Cale- I'hysician (1 thrugh you're not lequued to. 1'0111 1 Often hers the most knowledge of your medical history and can help you coordimac vour health cagy more ellwivclp. I'll() health plai nxnlhers now Ieceive Iwo sands lxr I:mlily. which .chow only the suhscnlurlpolicyholdei s Hanle. These card~ can hC Used by all members Covered On the policy. 11 you are• au Anthem Blkie Cross un:l WLIC 5hicld 1)fClltal KNIO mcmhcr: )'oil arc required to choose a prinruy denllSt. If yaU h:laC 1101 alrcody clone Su. we CncOm,kLC Vol] to ronlacl our CUstruuer SCyicC (lCpan nicnt 1oI assistance. To make the hest use of vour Anthem Blue Goss and Blue Shield hcnetits: C•an7• vour 11) card with you at tdl times and show it at each apprunUncrrt, four II) card inclu(Ics valuahlc hcnelil information that is helpful lu your provider. 13e rm brfirrrnul curd wise cuusunrer. 1'irrr are reeprur,ciMe for kuuniup your pfau's covered services, and what cu.cts you are required tip pay. Find this inlbr oration ill your cenihcate of cOvergie ov hcnelil booklet. and Icl'ei Io it hClbrC you ICCC1VC care. Help my arake wire ur claims are arew-alely paid. If yqu have phaniiacy henclas., check Vol]] bill(S) allu lecciving VOUr prescriptiiul. For all other Ixne7its. nrvicw 111c [Explanation of benefits (EOli) qua receive in the mail lollowim, scrvices;c If you are covered by More than one hcnelil plan. or it you .simply need help. please toniacl Cusurnlcr Service. Visit antheinxili r mill regisler h) use the ilwv l iuhem Solt Service lools, ihlxndilhg oil the AIIIIICIII IxvetitS you have, VOU C:uh view your henclits and copays. check the status of a Claim- find d PllIVicler using the online provider directnly. get 11CAL11 tips at A?vHcahh,00A hem. :uxl Save nxmev with the health- VokItcd disCOUnts upend through Speclal`Qfl.n, Cnfl nthenr. ive are h rt, ro serve you. Wi1en Vol have questions, call us a( the cuslomerScrvice- nanlixlon your ili, cairn. Or uscahe I'vivAnthrn) scii= wtvice took o❑ Untjwol.conr A fCw carry aclio s can help you make wise hc;Illh Care choice and hell) keep yu:llity care dffurdalhle 1 11[1: Visit the emergency rooUl or call 911 only when it's It u medical einel- )icy Contact Vow dentist lira dental emcrecncp it poll itiv a demal I-IN1O member. Re surd to Choose an in- network provider or lacility whenever Possible. ll' you have pharnhacv henefitS Willi us, chOOSC equivalent genclic chtltz.. I :Ither 1111111 more, czlxnsive hr:uld nantr dnlgs. Gel prevcluivc care and stay physiallly active to icnlai :l hcaltlly. "Thank you for hero' an Anthem b1tie Cross and lilue Shield mcmhcr. tit accc'p11n L_' dll,c (';Ird 1111,1 :1171' I)CllClils Ifi L4111(hl Ill is c:lyd ell Lilly 1111; Ill Ilic hold..', r :IC.1.n11N l,,JLc4 II1 :11 ill(' rider -y 1. 1111e11 11111 -Id 11 a 1 f1111 ",u'I 1111CII hclll'ecn Ih( I'Irhgk,ILIo 41,ld AI1111011 Alm.. 0111" ;md Itlue Sllielil. hl hld11111a1 Anlhollt Itiuo (2D)NN and Blur ShIdd is a lrado n:nne Ill Anlhcm i 111nL1• Cauywnlc>_ fur. lu Kcnluckc: Anlhoui Slue Cr and nine Shield is the trade name 1t A,ilh iii I InIlh 1'llm5ul Kcr i ins In l+his9ouri: AIIIhen, Itltic Cross and I91tic ,Shield is lhelradc moos It1- 11 It-'III IICIC Nl;magc(l Uan• Inc. rI2I I lcahhv Albano= I..ifc Insuentcc lbnlp :hl5' (I I I.ICI ;Ili d 1- t1111 :r ,4Iiss m. Inc. u sc. lo do husinCSS in 1111;1 of 4411 tnlri. HIT :old Mtam ahilialc,ti adminislcrnon- IiN4r1 hcnctirc wld .r's+'rillou bq IIAIJ(,' and IIN11) hcic.lits undcrlcrillcn lTv IINU) MIS- uri -11c I.Itc :111,1 disahilav products arc ,cderw,iuc,i by Alnhom I-ite. Insuranco r.fnn pa ll l' (A I.Il ft IT itn(l CCrlaill :1IfiIi 1[1.i 11111 [,,v\ adlll 111 loll a I, l .'C", ill, II seal l tll llded III jll,;illit 1,, III II Inldl:ll5I i k' IWOCI IT. 1111 Ill ill'. All(Ili III lithe (.fI Ill :111 lit lle. till icl lI 1l, 111(:113& 11UlIIC 111 C1II IITIIIIIli l 1' In.NIXAPICC G mp;nl v. In w"cnn.cin: 131nc Cnlss Ilhu Shield lrl �'.'I elinr:in 1 "I N_IiN I unduerihnv uI adminisl cl'.; the I'I't) uud indcnln ily I 11ci�.c; {,I I1pc.l rc le :dlh tivn'u•s Insurnnu. l' Irll I:Inun {'Cnmpalrc') ulltl[- iltltlic rlr ;tdnlini91cr5 Ill, 11rof poliCUS ;old Coln lJCUC and Ill ISSN, coil -muly undCl ll01 111' udnu nislcr the 14U\ pI Im". hnlopl :ndenl culnres Ill the filne Crl _.:old [dui+ Chlcld Assncialion. N9 nrcplt,ccnlalion ntay f-111 in the immcdialc canc0 nine of col rayC at IhC disCrcliun of the plan. 7322 If you have any questions concerning your account, please contact us Toll Free Automated Bankiina (800) 565-35 1" Live Personal, Banker. (800) 357 -6246 7am_9pm, CST, M -F i; '.j National leader in Health Savings Accounts. Fax:,(877) 8514041 A Division of Webster Bank,N.A. Internet Banking': www.hsabank.com P.O. Box 939 Mail. HSA Bank, 605 N. 8th Street, Suite 329, Sheboygan, Wl 53081 Sheboygan, WI 53082 -0939 YB e- mail: askus @hsabank.com.- Para un repiesentante eri'espanol, porfavorllamaral 866 357 6232' Richard C Marshall Jr r 18901106 ;x$6,337.1'4 578 Tulip Poplar Crest Carmel, IN 46033 M.061 =06!30 1 °$8:77 A 4° $994;24 160T4". '$5,351 ^f67� BAN HSA ACCOUNT _.K Nn(ionnf leaderin Health Savings A'Crou -n. .'9VAWRf LOWA r irr Ii0alth Savinlls ACc ants. SCPt[lttOR v x ta- s+ d.� a �0f1ItS�t >C[0C)]C3 =al�A�d[1CC BALANCE LAST STATEMENT 05/31/2009 6,337.14 FEE 7.95 06/15/2009 6,329.19 CHECK PRINTING FEE DISTRIBUTION/WITHDRAWAL 62.00 06/24/2009 6,267.19 01758486 MINUTECLINIC MINNIE 612- 659 -7111 MN DISTRIBUTION/WITHDRAWAL 663.30 06/2512009 5,603.89 76504043 MEDCOM 904- 5962246 FL DISTRIBUTIONANITHDRAWAL 260.99 06/26/2009 5,342.90 13763921 CVS PHARMACY #4635 CARMEL IN INTEREST PAID 8.77 06/30/2009 5,351.67 ANNUAL' PERCENTAGE YIELD EARNED FOR 30 DAYS,IS 1 INTEREST EARNED DURING CYCLE PERIOD 8 77 CURRENT`INTEREST RATE 1.739/o AVERAGE BALANCE FOR THIS STATEMENT CYCLE Hsa .AN K LISA Bank is a division of Webster Bank, N.A., Member FDIC fr'19414a! lfeufth Sni-ingr Aa:nmAS. Account Growth Potential By monthly contribution amount over time $6M.Ca Family maximum- In Case of Errors or Questions About Electronic Transfers $550, $483,33lmo. $5M.= If you need more information about an electronic transfer or you think there is an error on your $450,W $4oam°. statement that pertains to an electronic transfer, please telephone or write us as soon as possible at the 400, M phone number or address designated on the front of this statement. Errors must be reported to us no 0 $J00rm° later than 60 days after we sent you the FIRST statement on which the error or problem appeared. $300.M Singlerm imum- $250, 3 41681 1. Tell us your name and account number. $200. 2. Describe the error or the transfer you are unsure about, and explain to us as clearly as $sam $so, you can why you believe there is an error or why you need more information. 00 T]Olmo. $501mo. 3. Tell us the dollar amount of the suspected error. o 5 10 15 20 25 30 35 AO We will investigate your complaint and will correct any error promptly. If we take more than 10 business All figures are provided for illustration purposes. Actual days (20 business days if the error involved a "point -of- sale" debit card transaction or a transfer initiated savings and earnings may vary. For illustration purposes, outside of the United States) to do this, we will recredit your account for the amount you think is in error the following assumptions were used: average annual so that you will have use of the money during the time it takes us to complete our investigation. percent yield over the life of the HSA 4 and Y Y 9 p g maximum contribution limits remained constant. If you would like to confirm that an automatic deposit to your account has been made as scheduled, Are You Maximizing Your Tax Savings by please call us during normal business hours at the phone number designated on the front of this Contributing to Your HSA? statement or login to your account online. The maximum annual contribution (from all sources combined) is determined by the IRS. Limits for 2008 are $2,904 for single coverage In Case of Irregularities Identified On This Statement and $5,800 for family coverage. Contributions for a calendar year can be made until the tax- You must notify us within 30 days of the date we mailed or made this statement available to you of any filing deadline (typically April 15) of the unauthorized or missing signature or alteration on a check or other improper charges identified on this following year, NOT including extensions, statement, or within 60 days in the case of unauthorized or missing endorsement. Failure to notify us Accountholders who are 55 or older are also within the prescribed time periods or to commence action against us within 90 days after notice to us will eligible to make an additional catch -up preclude you from asserting claims against us based on such checks or charges. contribution, which is $900 for 2008. Remember, withdrawals for qualified medical expenses are tax -free, regardless of age or healthcare coverage, and if you have a In Case of Loss or Theft of your HSA Bank Debit Card balance after you turn 65, you can make withdrawals for non qualified expenses without To report the loss, theft, disappearance or suspected unauthorized use of this card or any disclosure of penalty, subject to regular income tax. This the PIN, call us at 800- 357 -6246, Monday through Friday, 7 am 9 pm, C1 allows you to use your HSA as you would use a retirement account, Change of Address You can update your address through online banking, https illsecure.hsabank.com/iibanking, or by calling us at 800 357.6246, Monday through Friday, 7 am 9 pm, CT. HSA Bank@ is a division of Webster Bank, N.A., Member FDIC O' 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 Sf�/✓��.� �oy5l�ry�� Purchase Order No. 57,'V �c�% ��Q v �'r�s7� Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 61110� U6 vI 0 9 Total 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 NO. ALLOWED 20 IN SUM OF s7� Tel 3 ON ACCOUNT OF APPROPRIATION FOR �oz/�f3 y 7SOG Board Members PO# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 9e 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 -12 20 0,5? S gnature Cost distribution ledger classification if It e claim paid motor vehicle highway fund