HomeMy WebLinkAboutCORRESPONDENCE - PURCHASE ORDER - 9150411Colorado Special Districts Property and Liability Pool
Workers' Compensation Invoice
Deductible Claim Billing
111f11101: Poudre Fire Authority and Poudre Valley Fire Pro jifdtF. Arthur J. Gallagher Risk Mgmt. Services
PO Box 580 6399 S Fiddlers Green Circle
Fort Collins, CO 80521 Suite 200
Greenwood Village, CO 80111
14W52807-2002 1 52807 31-Dec-14 05-Jan-15
Claim No.
Claimant
Year
Injury
Code
Deductible
Paid Loss
Recovered
Amount Due
WC2130310
CRAIG GEORGE
2013
M
$5,000
$477.81
$472.31
$5.60
WC2140431
BRYAN HANSON
2014
M
$5,000
$498.90
$480.71
$18.19
WC2140381
TIM MURPHY
2014
M
$5,000
$3.212.66
$2,147.77
$1 064.89
WC2140829
MARK SWIHART
2014
M
$5,000
$471.96
$0.00
$471.96
WC2140778
KARA BONHAM
2014
M
$5.000
$1,990.22
$0.00
_ $1,990.22
WC2140773
KEVIN LYON
2014
M
$5,000
$228.40
$0.00
$228.40
WC2140547
INIKOLAS GARTNER
2014
M
$5,000
$910.69
$807.18
$103.51
WC2140648
USAN FERRARI
2014
M
$5.000
$4,018.30
$0.00
$4,018.30
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Total Due: _ $7,900.97
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PAYMENT DUE UPON RECEIPT. Please remit a copy of this Invoice with your payment to the address
below. Payment or nonpayment of deductible amounts by a Member shall be treated under the coverage
forrn in the same manor as payment or nonpayment of contributions for coverage. Intergovernmental
Agreement Article 141 provisions will apply,
Please Remit To: Colorado special Districts Property and uabl ty pool
Uo MoGriQ Seibels 8 Williams, Inc.
P.O. Box 1539
Portland OR 97207-1639
Toll Free: 800318A8701 Fax: 50341436622
PrIM Dale: 05Jan-15