210030 06/20/2012 CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
Q� ONE CIVIC SQUARE HYLANT GROUP
CARMEL, INDIANA 46032 P 0 BOX 40925 CHECK AMOUNT: $51,472.50
INDIANAPOLIS IN 460824910 CHECK NUMBER: 210030
CHECK DATE: 6/20/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
302 5023990 794996 28,772.50 OTHER EXPENSES
302 5023990 794997 22,650.00 OTHER EXPENSES
1701 4347500 795318 50.00 GENERAL INSURANCE
HYLANT P.O. sox 40925
Indianapolis, IN 46280 -0925 INVOICE 794996 page
GROUP t Local: 317-817-5000
..�1CCOUYTNO SRd",_,
C ARME80 79 06/01/12
Workers Corii ensatlon
,�Z
x z� taw xc� i,*..• d r« r""° ...a,�z. R� "s s Y S
OLICI xv,xrv...
WCX002730
...:PRODUCER
W. Michael Wells
,...�EFF,ECTIV,E i
City of Carmel 01 /01/12 01 /01/13 07/01/12
7�x �x xy x
PAID,. ..1DIOUNTMUE a -r „,�.x
Steve Engelking 28,772.50
One Civic Square
Carmel, IN 46032
Aou
Eff Datev Tirn Type Pohcy�# Description
s a mnt;
..�..s :a�at
r„..}i
INVOICE 794996
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
D Q
JUN 18 2012 15
r�
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
MeTeln .P
HYLANT
India 0 9IN 46280- 0925Pa e ?1k
INVOICE 794997 g g
Local: 317 817 -5000
-5.. CSR'.,,,',a..'» ..,_.DATEa,s:._,.. �r,`._... ,k,.........
9ZGROUP OUNT,NO CARME80 79 06/01/12
Workers Compensation
WCX002730
wP.RODUCEIti_._ M0 _._....i�. u.".._ ..,..m'.2
W. Michael Wells
E
r
EFFECT1V�c:., ^:E�1'IRAT10N,�..���r,.��.. BAliANCE4DUEON .,.,tt:z•,. ...._:��L.
01/01/12 01/01/13 07/01/12
City of Carmel
iAPIOUNT,PAID......„ ,.w..._,.... d AMOUNT:DUE
Steve Engelking 22,650.00
One Civic Square
Carmel, IN 46032
es tion
INVOICE 794997
01 /01/12 RIS WC -S WCX002730 TPA Citizens Ins Co of America 22,650.00
WC/TPA INSTALL DUE 1/1/12 AND 7/1/12
Invoice Balance: 22,650.00
D Q
JUN 1 2012
ey_
301Pennsylvania Parkway Suite 201 P.O. Box 40925 Indianapolis, IN 46280 -0925
Toll Free: 800 678 -0361 Local: 317 817 -5000 Fax: 317 817 -5151
0
e
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
Hylant Group
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
06/01/12 794996 Worker Compensation $28,772.50
06/01/12 794997 Worker Compensation 22,650.00
Total $51,422.50
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 N0 NO.
ALLOWED 20
HVIant C3roun IN SUM OF
PO Box 40925
IN 46280925
$$51,42? 50
ON ACCOUNT OF APPROPRIATION FOR
302 WORK COMP FUND
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
794996 $28,772.50 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
HYLANT P.O. Box o o�iN 46280 o92s Pa
Local: 317 -817 -5000 INVOICE 795318 g�
4 GROUP M
CARM E80 79 06/05/12
BOND t t e P" r e
m
32S370620
W. Michael Wells
,EXPIRATION ,m..,„,+,,�` ,.„:BALANCE DUE,ON``
Cit of Carmel 07/20/12 07/20/20 07/20/12
ty
�..�MOUNTPAID,.;� .x.u.�. _...�4.;.,xa�A1170BNTDUE
Steve Engelking 50.00
One Civic Square
Carmel, IN 46032
EffDate Trn "Type Policy Descnpt�onfxK" Amount
INVOICE 795318
07/20/12 NEW BOND 32S370620 NOTARY BOND American States Insurance Co 50.00
NOTARY: LOIS A. FINE
Invoice Balance: 50.00
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
Ri
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
UY' Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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.
4WJ�U+ 6p ALLOWED 20
(r
IN SUM OF
TD Po 40
5b
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Mad S 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
20
1 6-4p, �-t
a:
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund