212394 08/28/2012 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1
ONE CIVIC SQUARE TRAVELERS
CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE CHECK AMOUNT: $563.60
r� CHICAGO IL 60693 CHECK NUMBER: 212394
CHECK DATE: 8/28/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 4347500 417773 324 .20 GENERAL INSURANCE
1125 R4358400 30307 417773 239 . 40 TORT CLAIM SETTLEMENT
TRAVELERS J� PAGE 1
THIS ACCOUNT IS SCHEDULED TO GO TO A COLLECTION AGENCY
IF PAYMENT IS NOT RECEIVED ON OR BEFORE THE DUE DATE.
GP09315757 5216X7087 07/31/2012 000417773 08/15/2012 5,054.73
,�'�� CURRENT
CLAIM#: EPS2377 DATE OF LOSS: 02/19/2011
DESCRIPTION: C-PARK,GREG VS CITY OF CARMEL POLICE MERIT BOARD.
COMPLAINT FILED AGAI
CLAIMANT: GREG PARK
EXPENSE 324.20
CLAIM TOTAL 324.20
CLAIM#: EQR4757 DATE OF LOSS: 06/13/2011
DESCRIPTION: C - MYERS, TERRY ALLEGATION OF DISCRIMINATION DUE TO
AGE. EEOC COMPLAI
CLAIMANT: TERRY D MYERS
EXPENSE 239.40
CLAIM TOTAL 239.40
CURRENT CHARGES $563.60
ACCOUNT SUMMARY
CURRENT CHARGES 563.60 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 4,491 . 13 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 5,054.73
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 5,054.73
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
D /A-\ p
AUG 27 2012
By
TRAVELERS
NON-FUNDED DEPARTMENT
ONE TOWER SQUARE -9MN
HARTFORD, CT 06183
00896 39049
CITY OF CARMEL, CARMEL CLAY PARKS BUILD
ONE CIVIC SQUARE
CARMEL IN 46032
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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))
07/31/12 000417773 $563.60
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
—C--lerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
Travelers
IN SUM OF $
13607 Collections Center Drive
Chicage, IL 60693
$563.60
ON ACCOUNT OF APPROPRIATION FOR
Administration Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT
Board Members
3,;?LF 36 1 hereby certify that the attached invoice(s), or
1205 000417773 43-475.00 .
bills) is (are)true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
Monday, August 27, 2012
Director, kministration
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
TRAVELERS J PAGE 1
RE C EWED
DEDUCTIBLE / SELF- INSURED INVOICE AUG 14 2012
BY:
GPO9315757 521GX7087 07/31/2012 000417773 08/15/2012 5,054.73
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.
TRA VELERS I PAGE 1
THIS ACCOUNT IS SCHEDULED TO GO TO A COLLECTION AGENCY
IF PAYMENT IS NOT RECEIVED ON OR BEFORE THE DUE DATE.
GP09315757 5216X7087 07/31/2012 000417773 08/15/2012 5,054.73
CURRENT
CLAIM#: EPS2377 DATE OF LOSS: 02/19/2011
DESCRIPTION: C-PARK,GREG VS CITY OF CARMEL POLICE MERIT BOARD.
COMPLAINT FILED AGAI
CLAIMANT: GREG PARK
EXPENSE 324.20
C-� }c,; 5 CLAIM TOTAL 324.20
CLAIM#: EQR4757 DATE OF LOSS: 06/13/2011
DESCRIPTION: C - MYERS, TERRY ALLEGATION OF DISCRIMINATION DUE TO
AGE. EEOC COMPLAI
CLAIMANT: TERRY D MYERS
EXPENSE 239.40
CLAIM TOTAL 239.40
CURRENT CHARGES $563.60
ACCOUNT SUMMARY
CURRENT CHARGES 563.60 INSURED NAME: CITY OF CARMEL,CARMEL CLAY PARKS BUILDIN
PAST DUE CHARGES 4,491 . 13 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 0.00 AGENT PHONE: (317) 817-5000
TOTAL DUE 5,054.73
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 5,054.73
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
Sri m i nn h rn ��ms
U?scription F
ucigat tie u E�fi
Line escr
rDate
urchaser ___
Data
Approval
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
362876 Travelers Terms
13607 Collections Center Drive
Chicago, IL 60693
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO# Amount
7/31/12 417773 Discrimination claim 30307 $ 239.40
Total I $ 239.40
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.
362876 Travelers Allowed 20
13607 Collections Center Drive
Chicago, IL 60693
In Sum of$
$ 239.40
ON ACCOUNT OF APPROPRIATION FOR
101 - General Fund
PO#or INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Dept#
30307 417773 4358400 $ 239.40 1 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
23-Aug 2012
Signature
$ 239.40 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund