HomeMy WebLinkAbout228725 1/28/2014 CITY OF CARMEL, INDIANA VENDOR: 362876 Page 1 of 1
ONE CIVIC SQUARE TRAVELERS CHECK AMOUNT: $8,526.47
CARMEL, INDIANA 46032 13607 COLLECTIONS CENTER DRIVE
CHICAGO IL 60693 CHECK NUMBER: 228725
CHECK DATE: 1/28/2014
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1125 4358400 453788 8, 526 . 47 REFUNDS AWARDS & INDE
TRAVELERS PAGE 1
DEDUCTIBLE / SELF- INSURED INVOICE [R_F JAN 132014
303GP64A-810 5216X7087 12/31/2013 000453788 01/15/2014 8,526.47
MAIL'PAYMENT TO: PAYER:
TRAVELERS CITY OF CARMEL,CARMEL CLAY
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
THE TOTAL DUE INCLUDES PAST DUE CHARGES.
PLEASE REVIEW YOUR ACCOUNT IMMEDIATELY.
303GPG4A-810 521GX7087 12/31/2013 000453788 01/15/2014 8,526.47
n�� < CURRENT
CLAIM#: EZK6237 1� DATE OF LOSS: 12/16/2013
DESCRIPTION: IV SLID ON SLUSHY ROAD INTO THE REAR OF OV.
CLAIMANT: STANLEY E CHEN
LOSS 8,526.47
CLAIM TOTAL 8,526.47
CURRENT CHARGES $8,526.47
ACCOUNT SUMMARY
CURRENT CHARGES 8,526.47 INSURED NAME: CITY OF CARMEL,CARMEL CLAY
PAST DUE CHARGES 1 ,043.07 AGENT NAME: HYLANT GROUP INC
UNAPPLIED PAYMENTS 1 ,043.07- AGENT PHONE: (317) 817-5000
TOTAL DUE 8,526.47
DISPUTED ITEMS 0.00
ACCOUNT BALANCE 8,526.47
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 1-860-277-6812 ANTONIO CONTRERAS
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Purchaser Date
Approval _ — ———Da:e
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bill to b properly e ro erly itemized must show; kind of service,where er ounit de ates service rendered, by
er
c.
whom, rates per day, number of hours, rate per hour, number of units, pricep
Payee Purchase Order No.
Terms
362876 Travelers
13607 Collections Center Drive
Chicago, IL 60693
Description PO# Amount
Invoice Invoice or bill s
(or note attached invoices) ( )) $ 8,526.47
Date Number
Insurance claim on Park Maintenance incident
12131113 453788
Total $ 8,526.47
e audited same in accordance
I hereby certify that the attached invoice(s),or bill(s)is(are)true and correct and I hav
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$
$ 8,526.47
ON ACCOUNT OF APPROPRIATION FOR
101 -General Fund
PO#orBoard Members
INVOICE NO. CCT#/TITL AMOUNT
Dept#
1125 453788 4358400 $ 8,526.47 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
21-Jan 2014
Of
Signature
$ 8,526.47 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund