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Home My WebLink About215787 12/18/2012 „Mf CITY OF CARMEL, INDIANA VENDOR: 366756 Page 1 of 1 ONE CIVIC SQUARE U S A A GENERAL INDEMNITY COMPA CARMEL, INDIANA 46032 PO BOX 33490 HECK AMOUNT: $1,369.37 o� SAN ANTONIO TX 78265 CHECK NUMBER: 215787 CHECK DATE: 12/18/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1110 4351000 26201 022465741-4 1, 369 . 37 6/4/2012 IN 9800 Fredericksburg Road :is qg San Antonio,Texas 78288 USAW CITY OF CARMEL PD December 12, 2012 3 CIVIC SQUARE CARMEL IN 46032-2584 Action Needed: Reimbursement of Payment Dear Sir or Madam, On July 19, 2012, we issued a payment to you in the amount of $1,369.37 in error for the claim referenced below: Policyholder: Kenneth Clesen Claim #: 022465741-4 Date of loss: June 4, 2012 Loss location: Indianapolis, Indiana We're asking that you reimburse us for the payment. Please use the enclosed form when returning the overpayment, and include your claim number and date of loss on your check or money order. Contact us to arrange making installment payments if you're unable to forward the entire amount. If we do not hear from you within 30 days, we'll be forced to assign this matter for collections. If you have questions, please call a member service representative at 1-800-531-USAA (8722). Sincerely, ��4-e j654-y�� Jennifer Rodriguez Injury Operations - SAT USAA General Indemnity Company PO Box 33490 San Antonio, TX 78265 Phone: 1-800-531-8722, Ext. 61535 Fax Phone: 1-800-531-8669 Enc: Payment Remittance Form - 88290 022465741 - DM-01776 -4 - 6844 - 10 54555-0612 Page 1 of 1 022465741 - 4 Payment Remittance Form Please enclose this form with your payment Policyholder: Kenneth Clesen Reference #: 022465741-7101-4-6844 Date of loss: June 4, 2012 Amount owed: $ 1,369.37 Amount enclosed: $ Your name: Address: Home phone: Business phone: Thank you for your payment. Return this form to: 0027 P&C Claims Shared Services ASA II COE 9800 Fredericksburg Road San Antonio, Texas 78284-8499 88290-0508 MAIL DIRECT 03292 . M2G6 . JSS430330400 . 01 . 01 . 484 RECEIVED CITY OF CARMEL PD ATTN: VICKI BAILEY 3 CIVIC SQUARE JUL 2 3 2012 CARMEL, IN 46032 CARMEL POLICE DEPT USAA General Indemnity Company PO Box 33490 San Antonio, TX 78265 INVOICE #: USAA-41570224606397036080 LOB: AUT USAA # : 022465741 CLAIMS REP: 06844-10 LOSS RPT # : 4 CHECK # : 0003246835 LOSS DATE: 06/04/2012 CHECK DATE: 07/19/2012 POLICYHOLDER: KENNETH CLESEN EXPLANATION OF PAYMENT TOTAL PAYMENT AMOUNT Payment under Property Damage Liability Coverage City $**1 , 369. 37 of Carmel PD, 2009 CHEVROLET IMPALA LS 93868-1209 18433-0709 p .o o m It; •v!'Sdof�Lr o�oS3�':• a s u° Y cTS o Rrff7 AAA7 05 1 �Iy!'+, USAAI General) Indemnity Company DATE IIIht� Poi 'Box 33490, 07/19/2012 VuII,II ' iSanl''Antonio, TX 78265 CHECK. AMOUNT $**1, 369. 37 PAY **One Thousand Three Hundred Sixty:-Nine and 37/100 s** TO , CITY OF CARMEL PD THE,- ORDER OF - fq,n .''I,III, *,,11^•Pp"';'?�;��Ildlll,., ,:�°ip�l„ �''a'"'^l°"liill',I,I I USAA #: 022465741 I LR #: 4 a li 1 ullillllli;ill5 I II SS I I Illh `i� �1�111iil hL�i ��ill 111!111' iIg44�g1��'ilill l�II�I��., ., iil.,,.. '•:e!i .I rc�, L,:„oo,I!�I�III, $ �+,III II,III,IIIII J�IIy,�}�, II IIIIIMV NATURE OF PAYMENT: r o Payment under Property Damage Liability Coverage City of Carmel PD, 2009 h ,III v i;ll CHEVROLET IMPALA LS *Si1,i',uiIIIIIiIPIII'I BANK OF AMERICA - HARTFORD, CT VOID 180 DAYS FROM ISSUE DATE AUTHORIZED SIGNATURE'" 11'000 3 2 4 68 3 511' 000 b b90044Si: 2 2400 LS66S11° C 0 INDIANA RETAIL TAX EXEMPT PAGE 1t , ®f C CERTIFICATE NO.003120155 002 0� PURCHASE ORDER NU:MBER j FEDERAL EXCISE TAX EXEMPT =1 35-60000972 ONE CIVIC SQUARE , THIS NUMBER MUST APPEAR ON INVOICES,A/P CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS, FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL- 1997 SHIPPING LABELS AND ANY CORRESPONDENCE. PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION ISMrAl2 HUbIQP ExpFoss Co : Ion Camel Policy Dopartmont VENDOR SHIP 3 CIVIC square 503 Wo @I Drivo yy TO Cumol, IN 466 Ca ol„ IN 4M (317)671 CONFIRMATION BLANKET CONTRACT PAYMENTTERMS FREIGHT QUANTITY UNIT OF MEASURE V DESCRIPTION UNIT PRICE EXTENSION Account 43-610.00 9 Each repairs to vehicle $1,369.37 $1,369.37 Sub Total: $1,369.37 _ wed R_,✓, -•,,....,'... �� ` , ,� ® d • A f' car 43/Robbing Send Invoice To: Carmel Pollce Departmont Attn. Toresa Anderson 3 Civic Squam Car mol, IN 46== PLEASE INVOICE IN DUPLICATE DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT Carmel Police Dept. PAYMENT $1,39.37 • A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED. SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT HERE IS AN UNOBLIGATED BALANCE IN •SHIP REPAID. THIS APPROP�A FFICIENT TOPAYFOR.T.HE ABOVE ORDER. •C.O.D.SHIPMENTS CANNOT BE ACCEPTED. •PURCHASE ORDER NUMBER MUST APPEAR ON.ALL ORDERED BY SHIPPING LABELS. '� Q p •THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE b (�° �l IPa `� AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. ®� CLERK-TREASURER DOCUMENT CONTROL NO. A.P.V. COPY-SIGN AND RETURN TO.CLERK'S OFFICE VOUCHER NO._.__...__..._....____ WARRANT NO..______...___ ALLOWED 20 -- __-. IN THE SUM OF$ ON ACCOUNT OF APPROPRIATION FOR 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 materials or services itemized thereon for which charge is made were ordered and received except__.._______ • t 20 ...........__............................_.............................__. _. -----------------------.......................-- Signature -_....._.__.................... ......__.........__...._._........__........._....._......_.............._.._............._...._...........__. — Title Cost distribution ledger classification if claim paid motor vehicle highway fund VOUCHER NO. WARRANT NO. ALLOWED 20 USAA General Indemnity Company IN SUM OF $ P.O. Box 33490 San Antonio, TX 78265 $1,369.37 ON ACCOUNT OF APPROPRIATION FOR Carmel Police Department PO#/Dept. INVOICE NO. ACCT#rrITLE AMOUNT Board Members 26201 I 022465741-4 I 43-510.00 I $1,369.37 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 Wednesday, December 12, 2012 Chief of Police Title Cost distribution ledger classification if claim paid motor 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 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)) 12/12/12 022465741-4 duplicate payment $1,369.37 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