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Home My WebLink About208332 04/25/2012 \�f CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1 ONE CIVIC SQUARE HYLANT GROUP CHECK AMOUNT: $4,861.00 ro CARMEL, INDIANA 46032 P O BOX 40925 INDIANAPOLIS IN 46082 -0910 CHECK NUMBER: 208332 CHECK DATE: 4125/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1205 4347500 790493 2,061.00 GENERAL INSURANCE 1205 4347500 790494 1,192.00 GENERAL INSURANCE 302 5023990 790756 1,608.00 OTHER EXPENSES L ANT P.O. Box 40925 Indianapolis, IN 46280 -0925 I N V ®ICE 790493 Paged 1 LOCaI: 317 817-5000 A GCOUNT „NU ?`,ru °'.CSR ,wr".i�"`;!' n,.:'D�TF y GROUP CARME -9 79 04/11/12 PRODUCER�4p. w. ,.;:+i .x,i. }n`. J� ab.a, W. M ichael Wells >_R,ILANCE DUE ON...�,.� ':w�� r 04/12/12 IOUNTRAIM "I s, ...<x. .,An10UNTiDUB 2,061.00 Carmel Farmers Market, Inc. Ron Carter 12715 Stanwich Place Carmel, IN 46033 A N!� Eff,Date Trn Type Policy Descriptron±� I �Jiiii INVOICE 790493 04/12/12 REN GL -S P6605046C259TIL12 GENL LIABILITY Travelers Insurance Companies 2,061.00 Invoice Balance: 2.061.00 301 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 YI ANT ndi Bapoi��irr 46280 -o92s INVOICE 790494 Paged T GROUP Local: 317 -817 -5000 s,CCOUivT NO r_ ,.CSIt ,.,,,,.�,tDQTE nw ,„;::,,,,„arfi�"" `T7S CARME -9 79 04/11/12 W. Michael Wells K° B 1L �NCEtDUE 04/12/12 AMOUN,T,PA{D �.t,.�`....:.,. w ADIOUN,T,�DUE...„xse;�� 1,192.00 Carmel Farmers Market, Inc. Ron Carter 12715 Stanwicb Place Carmel, IN 46033 ar INVOICE 790494 04/12/12 REN DOLI 104733360 D &O POLICY Travelers Insurance Companies 1,192.00 Invoice Balance: 1,192.00 301 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 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)) 04/11/12 790493 $2,061.00 04/11/12 790494 $1,192.00 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 N ALLOWED 20 Hylant Group IN SUM OF 301 Pennsylvania Parkway, Suite 201 Indianapolis, IN 46280 -0925 $3,253.00 ON ACCOUNT OF APPROPRIATION FOR Administration Department PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members 1205 790493 43- 475.00 $2,061.00 1 hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the 1205 790494 43- 475.00 $1,192.00 materials or services itemized thereon for which charge is made were ordered and received except Mort ay, April 23, 2012 Director, r Administr I Title Cost distribution ledger classification if claim paid motor vehicle highway fund P.O. Box 40925 Indianapolis, DN46zV0-O925 Local: 317-817-5000 ME ,"AGROUP CARME80 79 04/13/12 W. Michael Wells 01/01/09 01/01/12 04/13/12 City of Carmel Steve One Civic Square Carmel,]N 46032 INVOICE rvorm 01m1/09 AuoWo-S vwrXonzr»o WORK COMP FINAL AU Citizens Ins CvorAmerica 1/60800 i vmzuoosRS COMP FINAL AUDIT PERIOD ou/1'u Invoice Balance: 1,608.00 3OzPcuumlvuuia Parkway Suite u01`P.o. Box 4092j` Indianapolis, nv4628O'O92j Toll Free: 000'«7V-B61 Local: 3\7-8\7-5OOo`Fun:3l7-8i7-5m1 CITIZENS MANAGEMENT INC. WORKERS' COMPENSATION AUDIT GROSS EXCESS PREMIUM ACCOUNT: City of Carmel EXCESS POLICY TERM: 01 -01 -09 to 01 -01 -12 AUDIT TERM: 01 -01 -11 to 01 -01 -12 POLICY WCX 002730 ESTIMATED ANNUAL PAYROLL: $37,193,331 ESTIMATED ANNUAL STANDARD PREMIUM- GROSS EXCESS RATE: 13.90% ESTIMATED ANNUAL EXCESS PREMIUM: $56,227 AUDITED PAYROLL: $39,452,286 AUDITED STANDARD PREMIUM: $416,077 GROSS EXCESS RATE: 13.90% AUDITED EXCESS PREMIUM: $57,835 ANNUAL MINIMUM EXCESS PREMIUM: $55,102 GROSS ADDITIONAL EXCESS PREMIUM DUE: $1,608 11 -12 audit 4/6/2012 12:31 PM CITIZENS MANAGEMENT INC. WORKERS' COMPENSATION AUDIT ACCOUNT: City of Carmel SERVICE CONTRACT TERM: 01 -01-09 to 01 -01 -12 EXCESS POLICY TERM: 01 -01 -09 to 01 -01 -12 AUDIT TERM: 01 -01 -11 to 01 -01 -12 AUDIT TERM: 01 -01 -11 to 01 -01 -12 POLICY WCX 002730 SELF INSURED RETENTION: $300,000 MINIMUM AGGREGATE RETENTION: $606,522 STANDARD PREMIUM AUDIT........ LOCATION CODE CLASSIFICATION AUDITED RATE STANDARD PAYROLL PREMIUM 5506 Street or Road $2,343,395 3.04 71,239 7520 Water Works $2,280,904 1.69 38,547 7580 Sewage Disposal $1,528,344 1.43 21,855 8380 Auto Repair Facility $342,491 1.16 3,973 8810 Clerical $8,269,121 0.11 9,096 9410 Municipal Employees $1,005,486 1.14 11,463 8869 Child Day Care Center $1,609,125 0.36 5,793 9015 Buildings NOC $528,467 1.53 8,086 9102 Parks NOC $2,151,198 1.29 27,750 7699 Firefighter Med Only $11.,388,400 1.39 158,299 7725 Police Med Only $7,767,342 0.77 59,809 8820 Attorney $238,013 0.07 167 TOTAL: $39,452,286 416,077 11 -12 audit 4/6/2012 12:31 PM EXCESS POLICY FINAL AUDIT ENDORSEMENT ACCOUNT: City of Cannel EXCESS POLICY TERM: 01 -01 -09 to 01 -01 -12 AUDIT TERM: 01 -01 -11 to 01 -01 -12 POLICY WCX 002730 As provided for in Condition II, Premium, the calculation of audited Standard Premium for the policy period has been computed by applying the rates in Schedule A to the audited remuneration during the policy term. Audited Item II Schedule A CODE CLASSIFICAnoN 0101 -11 TO 01 -01 -12 RAPE PREMIUM 5506 Street or Road $2,343,395 3.04 $71,239 7520 Water Works $2,280,904 1.69 $38,547 $1,528,344 1.43 $21,855 8380 Auto Repair Facility $342,491 1.161 973 8810 Clerical $8,269,121 0.111 $9,096 9410 Municipal Employees $1,005,486 1.14 $11,463 8869 Child Day Care Center $1,609,125 0.36 $5,793 9015 Buildings NOC $528,467 1.53 $8,086 9102 Parks NOC $2,151,198 1.29 $27,750 7699 Firefighter Med Only $11,388,400 1.39 $158,299 7725 Police Med Only $7,767,342 0.77 $59,809 8820 Attomey $238,013 0.07 $167 TOTAL: $39,452,286 $416,077 AUDITED REMUNERATION: $39,452,286 ESTIMATED REMUNERATION: $37,193,331 DIFFERENCE: $2,258,955 Audited Item V AUDITED STANDARD PREMIUM: $416,077 ESTIMATED POLICY STANDARD PREMIUM: $404,510 DIFFERENCE: $11,567 The audited Standard Premium has been multiplied by the percentage of Standard Premium stated in Item V for determination of the audited Excess Premium. PERCENTAGE OF STANDARD PREMIUM: 13.90% AUDITED POLICY PERIOD EXCESS PREMIUM: $57,835 ESTIMATED POLICY PERIOD EXCESS PREMIUM: $56,227 DIFFERENCE: $1,608 If the eamed premium thus computed exceeds the premium previously paid, the insured shall pay the difference to the company within 45 days. If the earned premium thus computed is less than the premium previously paid, the Company shall pay the difference to the insured within 45 days. Audited Item VI (a) Self- Insured Retention Each Occurrence: $300,000 (b) Minimum Aggregate Self- Insured Retention: $606,522 (c) Aggregate Self- Insured Retention: 153 of the policy period standard premium. Audited Aggregate Retention: $636,598 11 -12 audit 4/6/2012 12:31 PM EXCESS POLICY FINAL AUDIT ENDORSEMENT ACCOUNT: City of Carmel EXCESS POLICY TERM: 01 -01 -09 to 01 -01 -12 AUDIT. POLICY TERM: 01 -01 -11 to 01 -01 -12 POLICY WCX 002730 AUDITED STANDARD PREMIUM: $416,077 AGGREGATE RETENTION PERCENTAGE: 153 AUDITED AGGREGATE RETENTION: ...$636,598 MINIMIUM AGGREGATE RETENTION: $606,522 INCURRED LOSSES AS OF 02- 29-12: $598,143 PAID LOSSES AS OF 02- 29 -12: $405,756 SELF- INSURED RETENTION: $300,000 LOSSES OVER THE SPECIFIC RETENTION: None 11 -12 audit 4/6/2012 12:31 PM 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 Hyl Group Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 04/17/12 790756 Work Comp Audit $1,608.00 Total $1,608.00 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 N00 NO. ALLOWED 20 Hylant Group IN SUM of PO Box 40925 Indianapolis IN 46280 -0925 $1,608.00 ON ACCOUNT OF APPROPRIATION FOR 302 Workers Compensation Board Members PO# or DEPT. INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the 790756 302 11,608.00 materials or services itemized thereon for which charge is made were ordered and received except 20 r Signa ure Title Cost distribution ledger classification if claim paid motor vehicle highway fund