172588 05/13/2009 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1
ONE CIVIC SQUARE TRAVELERS
%o CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK AMOUNT: $10,698.50
CHICAGO IL 60693 CHECK NUMBER: 172588
CHECK DATE: 5113/2009
DEPART ACCOUNT PO NUMBER INVOICE NUMB AMOUNT DESCRIPTIO
1120 4347500 38.10 GENERAL INSURANCE
1205 4347500 318494 10,000.00 GENERAL INSURANCE
1205 4347500 318676 660.40 GENERAL INSURANCE
TRAVELERS PAGE i
J
DEDUCTIBLE INVOICE
i
GPO9311918 0018277244 04/30/2009 000318494 05/15/2009 10,000.00
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL
13607 COLLECTIONS CENTER DRIVE ATTENTION: B COOK
CHICAGO, IL 60693 1 CIVIC SQUARE
CARMEL IN 46032
RETURN THIS PORTION WITH YOUR CHECK MADE PAYABLE TO TRAVELERS.
PLEASE WRITE THE POLICY ACCOUNT NUMBER ON YOUR CHECK.
TRAVELERS PAGE i
GPO9311918 0018277244 04/30/2009 000318494 05/15/2009 10,000.00
CURRENT
CLAIM#: 13AO01 DATE OF LOSS: 06/29/2005 rr
DESCRIPTION: C ESTATE OF ALYSSA MCCANN TORT CLAIM NOTICE ARISING s.
OUT OF THE DEATH O
CLAIMANT: ALYSSA MCCANN
LOSS 10,000.00
CLAIM TOTAL 10,000.00
CURRENT CHARGES $10,000.00
ACCOUNT SUMMARY
CURRENT CHARGES 10,000.00 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 10,000.00
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 10,000.00
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE 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
TRAVELERS
NON- FUNDED DEPARTMENT
ONE TOWER SQUARE -9CR
HARTFORD, CT 06183
39756
CITY OF CARMEL
ATTENTION: B COOK
1 CIVIC SQUARE
CARMEL IN 46032
0
0
0
0
0
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0
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TRAVELERS PAGE
DEDUCTIBLE INVOICE
POLICYAUMBER i i
GP093i3908 521GX7087 04/30/2009 000318676 05/15/2009 12,816.36
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL; CARMEL CLAY PARKS
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.
TRAVELERS) PAGE 1
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
GP09313908 521GX7087 04/30/2009 000318676 05/15/2009 12,816.36
CURRENT
CLAIM CES0074 DATE OF LOSS: 03/11/2008
DESCRIPTION: C BELL, LOGAN ALLEGATIONS THAT CPD TOOK UNREASONABLE (1 \G
ACTIONS IN LIEU
CLAIMANT: LOGAN BELL
EXPENSE 660.40
CLAIM TOTAL 660.40
CLAIM#: CES0119 DATE OF LOSS: 01/06/2008
DESCRIPTION: C HOFF, MARGARET. CLMNT WAS FOUND UNRESPONSIVE
CARMEL FIRE DEPT RE
CLAIMANT: MARGARET C HOFF
EXPENSE 38.10
CLAIM TOTAL 38.10
CLAIM CES1746 DATE OF LOSS: 01/21/2009
DESCRIPTION: OV SLOWING DOWN FOR ROUND ABOUT AND IV WAS BEHIND, DID U'
NOT SLOW DOWN I
CLAIMANT: LAURA GALYAN
LOSS 3,416.10
CLAIM TOTAL 3,416.10
CURRENT CHARGES $4,114.60
TRAVELERS
NON- FUNDED DEPARTMENT
ONE TOWER SQUARE -9CR
HARTFORD, CT 06183
38944
CITY OF CARMEL; CARMEL CLAY PARKS
ONE CIVIC SQUARE
CARMEL IN 46032
0
m
0
0
0
0
Q
0
0
ti
AINMW
TRAVELERS J PAGE 2
DEDUCTIBLE INVOICE
GPO9313908 5216X7087 04/30/2009 000318676 05/15/2009 12,816.36
ACCOUNT SUMMARY
CURRENT CHARGES 4,114.60 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 8,701.76 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 12 816.36
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 12,816.36
CONTACT.YOUR.AGENT LISTED-ABOVE _IF._ YOU_ HAVE- .QUEST.IONS_.RELATED.TO YOUR POLICY OR DEDUCTIBLE 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
TRAVELERS
NON- FUNDED DEPARTMENT
ONE TOWER SQUARE -9CR
HARTFORD, CT 063$3
38943
CITY OF CARMEL; CARMEL CLAY PARKS
ONE CIVIC SQUARE
CARMEL IN 46032
0
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0
N
Q
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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
Tr avelers Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
W381 3 i 8494 DOE 0 /297/2-005
04410109— .1 11119009
Total$1b
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 Nay j _VL WARRANT NO.
ALLOWED 20
$607 C ollections C enter Drive IN SUM OF
Chicago, IL 60693
$10,660.40
ON Accou 'GE�NERAL FUND N F
1205 Administration
Board Members
PO# or
DEPT. INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify that the attached invoice(s), or
1205 318494 475 0 bills) is (are) true and correct and that the
materials or services itemized thereon for
1285 3 18676 $660.40 which charge is made were ordered and
received except
20
6 aft l re
Title -i-
Cost distribution ledger classification if
claim paid motor vehicle highway fund
TR /{d J
ELERS I PAGE 1
y µq
DEDUCTIBLE INVOICE
i .W' S
GPO9313908 5216X7087 04/30/2009 000318676 05/15/2009 12,816.36
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL; CARMEL CLAY PARKS
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.
TRAY `LERS J PAGE 1
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
i
GPO9313908 5216X7087 04/30/2009 000318676 05/15/2009 12,816.36
CURRENT
CLAIM CES0074 DATE OF LOSS: 03/11/2008
DESCRIPTION: C BELL, LOGAN ALLEGATIONS THAT CPD TOOK UNREASONABLE
ACTIONS IN LIEU
CLAIMANT: LOGAN BELL
EXPENSE 660.40
CLAIM TOTAL 660.40
CLAIM CES0119 DATE OF LOSS: 01/05/2008
DESCRIPTION: C HOFF, MARGARET, CLMNT WAS FOUND UNRESPONSIVE
CARMEL FIRE DEPT RE
CLAIMANT: MARGARET C HOFF
EXPENSE 38.10
CLAIM TOTAL 38.10
CLAIM CES1746 DATE OF LOSS: 01/21/2009
DESCRIPTION: OV SLOWING DOWN FOR ROUND ABOUT AND IV WAS BEHIND, DID
NOT SLOW DOWN I
CLAIMANT: LAURA GALYAN
LOSS 3,416.10
CLAIM TOTAL 3,416.10
CURRENT CHARGES $4,114'.60
TRAVELERS J PAGE 2
DEDUCTIBLE INVOICE
GP0931390B 5216X7087 04/30/2009 000318676 05/15/2009 12,816.36
ACCOUNT SUMMARY
CURRENT CHARGES 4,114.60 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 8,701.76 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817 -5000
TOTAL DUE 12,816.36
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 12,816.36
CONTACT YOUR AGENT LISTED ABOVE IF YOU HAVE QUESTIONS RELATED TO YOUR POLICY OR DEDUCTIBLE 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
Prescribed by State Hoard 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))
$38.10
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.
Travelers ALLOWED 20
IN SUM OF
13607 Collections Center Drive
Chicago, IL 60693
$38.10
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO41 Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1120 43- 475.00 $38.10 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
which charge is made were ordered and
received except
MAY 11 ?009
C
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund