HomeMy WebLinkAbout215266 12/10/2012 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1
i,�l0 ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $5,000.00
•=o CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE
CHICAGO IL 60693 CHECK NUMBER: 215266
CHECK DATE: 12/10/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 423689 5, 000 . 00 OTHER EXPENSES
9 v L E RS J PAGE 1
DEDUCTIBLE / SELF- INSURED INVOICE
191 illi
14N99887-ZPP 5216X7087 10/31/2012 000423689 11/15/2012 5,000.00
MAIL PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL, CARMEL CLAY PARKS BUIL
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.
AW
TRAVELERS J PAGE 1
i
14N99887-ZPP 5216X7087 10/31/2012 000423689 11/15/2012 5,000.00
CURRENT
CLAIM#: ESE3517 DATE OF LOSS: 06/05/2012
DESCRIPTION: WATER PIPE BROKE IN ROOM 515 AND IT ENDED UP FLOODING A 1"
17 ROOMS
CLAIMANT. /CARMEL HOTEL LLC
LOSS 5,000.00
CLAIM TOTAL 5,000.00
CURRENT CHARGES $5,000.00
ACCOUNT SUMMARY
CURRENT CHARGES 5,000.00 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 5,000.00
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 5,000.00
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
TRAVELERS
NON-FUNDED DEPARTMENT
ONE TOWER SQUARE -9MN
HARTFORD, CT 06183
00846 39099
CITY OF CARMEL, CARMEL CLAY PARKS BUIL
ONE CIVIC SQUARE
CARMEL IN 46032
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VOUCHER # 123005 WARRANT # ALLOWED
T2291 IN SUM OF $
TRAVELERS
13607 COLLECTIONS CENTER DRIVE
CHICAGO, IL 60693
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
423689 01-6570-06 $5,000.00
Voucher Total $5,000.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
T2291
TRAVELERS Purchase Order No.
13607 COLLECTIONS CENTER DRIVE Terms
CHICAGO, IL 60693 Due Date 12/7/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/7/2012 423689 $5,000.00
1 hereby certify that the attached invoice(s), or bill(s) is (are) true and
:orrect and I have/audited same in accordance with IC 5-11-10-1.6
Date Officer