HomeMy WebLinkAbout216073 01/09/2013 CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
ONE CIVIC SQUARE HYLANT GROUP
.� CARMEL, INDIANA 46032 P 0 BOX 40925 CHECK AMOUNT: $51,422.50
INDIANAPOLIS IN 46280-5000 CHECK NUMBER: 216073
CHECK DATE: 1/9/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
302 5023990 811899 28, 772 . 50 OTHER EXPENSES
302 5023990 811900 22 , 650 . 00 OTHER EXPENSES
Eff Date, Trn Type.- Policy#. Description;,a Amount '
s,•
INVOICE# 811900
01/01/12 CFE WC-S WCX002887 SERVICE FEE Citizens Ins Co of America $ 22,650.00
Invoice Balance: $ 22,650.00
Fy-
30 N 0 7 2013
1 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
Ris 1
i
„
Eff Date,Trn Type Policy#. ;:; Description•; Amount,. t
INVOICE# 811899
01/01/12 RIS WC-S WCX002887 WC PREMIUM Citizens Ins Co of America $ 28,772.50
Invoice Balance: $ 28,772.50
D Q �
JAN 0 7 2013
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
• 40
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))
12/13/12 811899 Workers Compensation Policy RIS 28,772. 0
12/13/12 811900 Workers Compensation Policy CFE $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 1\19T/072013 WARRANT NO.
ALLOWED 20
HYLANT GROUP IN SUM OF $
301 Pennsylvania Parkway, Suite 201
Indianapolis, IN 46280
$ $151,422 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
811899 302 $28,772.50 materials or services itemized thereon for
811900 S22 650 which charge is made were ordered and
received except
20
r
Sig ature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund