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Home My WebLink AboutCRA-R-06-0004 Back-upCity of Miami REQUEST FOR DIRECT PAYMENT INSTRUCTION: Please attach all the original documents related to expenditures, i.e., receipts, bills, invoices, etc. FROM Name: lCICU CA 2. epartment: / ! �.1>>'Y1/i��lr�;"1`-u 1c� If'IieI::.7'6n 3. riff ! AT +) , h_ J --Yi, t.e. OK(' . Pr a. pate: 01 : J f f� r' kil .2336- TO CHIEF ACCOUNTANT, ACCOUNTING DIVISION, FINANCE DEPARTMENT ISSUE CHECK TO 5. Name: ( j +-rP -Pe r re,-( G ..i•-ke e e) 0) e4� +r✓t l 6. Address: x �{ �{ r7 O . 1 o` try✓ �5 j,cf k-, DESCRIPTION. OF ITEM(S) TO BE PAID ACCOUNT CODE/ SUBSIDIARY NO. AMOUNT 7. �; ��:.c rls C�� — - 2 O5 2 u� ca -r r Poise` ()6\ bl7 (SU.2 2.105 600Oky. DATE.10 Mil10. MO A 5011. 5 s9/A' III Of— r , 9115 S( ►1.0) Check Distribution: [❑ ail Direct to Vendor Return to Department TOTAL PAYMENT 11. Q L/ n 12. Ap /0171ir Approved: ) f 1 Department Director/Designee Date Expenditure Control Date Approved"' /) FOR FINANCE USE ONLY 1 ` Al -1 i i/ 5 I Vendor No: Check No: Date: Fisnce`/Ci }I Manager Date \\I C FOR REQUESTING DEPARTMENT USE ONLY Batch No: Pre -encumbered By: Date: l 1 Control Numie�'r` 1 q1 :s i 1 t1 DP-4 C �FN/AC 202 Rev. 12/89 , Route: White and Canary copies to Expenditure Control and retain Pink copy. Distribution: White and Canary - Finance (Accounting) 4 3 11 b _$. 1. 1 .MObNT 42320 10/14/2005 431168 • 001000000282105 10/03/052005-06 WORKERS CO 5594.00 PREFERRED GOVERNMENTAL INSURANCE TRUST 10/14/2005 431168 5594.00 0.00r 5594.0( 0.00i 5594.00 431168 ******5,594.00 FIVE THOUSAND FIVE HUNDRED NINETY FOUR DOLLARS AND 00 CENTS PREFERRED GOVERNMENTAL INSURANCE ?RUB �� '-,�' " P 0 BOX 958455 c� oifiEcfo?~�'r`� .�� LAKEMARY, FL 32795 r ~'k . -"•' "tea' r' � v4311.680 1:06 700643 24 2696 2041334756v L k9a5T0 /7, v � . 7 N. a r.) P R E M I=U M NOTICE Public Risk Underwriters P.O. Box 958455 Lake Mary, FL 32795-8455 Due Date Southeast Overtown Park Community 49 NW 5th Street, Ste. 100 Miami, FL 33128 10/03/2005 10/03/2005 Transaction Description Previous Unpaid Balance October Billed Premium Expense Constant Due Total Amount Due Date of Bill: 10/03/2005 Policy #: 001000000282105 Division: 00000 Policy Year: 105 Amount Due: $ 5,594.00 Due Date: 10/03/2005 Amount $ .00 $ 5,394.00 $ 200.00 $ 5,594.00 Please make checks payable to: Preferred Governmental Insurance Trust Serviced by: Public Risk Underwriters Direct Inquiries to: WORK COMP UNIT (321) 832-1450 APPROVED Agent: 5 Brown & Brown, Inc. P. 0. Box 2412 Daytona Beach, FL 32115 (386) 252-9601 Please return copy of Make checks payable to: Preferred Southeast Overtown Park Community 49 NW 5th Street, Ste. 100 Miami, FL 33128 Public Risk Underwriters P.O. Box 958455 Lake Mary, FL 32795-8455 notice with your remittance. Governmental Insurance Trust Date of Bill: 10/03/2005 Policy #: 001000000282105 Division: 00000 Policy Year: 105 Amount Due: $ Due Date: Amt Enclosed: 5,594.00 10/03/2005 ESTMATEDBILLG Preferred Governmental Insurance Trust P.O. Box 958455 Lake Mary, FL 32795-8455 Southeast Overtown Park Community 49 NW 5th Street, Ste. 100 Miami, FL 33128 Print Date: Policy #: Division: Policy Period: 8/30/2005 001000000282105 00000 10/01/2005-10/01/2006 Agent #: 5 Brown & Brown, Inc. P. O. Box 2412 Daytona Beach, (386) 252-9601 Rating State: FL FL 32115 Code Classification Payroll Rate Premium 5645 CARPENTRY CONSTRUCT 8810 CLERICAL Standard liability limits: 1000/1000/1000 Serviced by: :Public Risk Underwriters P.O. Box 958455 Lake Mary, FL 32795-8455 38.40 566,937 .64 Phn# (321) 832-1450 0 3,628 LESTERP Page 1 ESTIMATED BILLING Preferred Governmental Insurance Trust P.O. Box 958455 Lake Mary, FL 32795-8455 Southeast Overtown.Park Community 49 NW 5th Street, Ste. 10D Miami, FL 33128 Manual Premium Print Date: Policy #: Division: Policy Period: 8/30/2005 001000000282105 00000 10/01/2005-10/01/2006 Agent #: 5 Brown & Brown, Inc. P. O. Box 2412 Daytona Beach, FL 32115 (386) 252-9601 Subject Premium Experience Modifier Standard Premium Stock Discount Normal Premium Expense Constant Estimated Premium Premium Eff Date, ExD Date 1.0000 0.88% 3,628.00 3,628.00 3,628.00 1,814.00+ 5,442.00 48.00- 5,394.00 200.00+ 5,594.00 Expense Constant Premium Paid Balance $5,594.00 Payment Plan: 25% DOWN 9 EQUAL INSTALLMENTS Due October 1, 2005 1,548.50 Due November 1, 2005 449.50 Due December 1, 2005 449.50 Due January 1, 2006 449.50 Due February 1, 2006 449.50 Due March 1, 2006 449.50 Due April 1, 2006 449.50 Due May 1, 2006 449.50 Due June 1, 2006 449.50 Due July 1, 2006 449.50 5,394.00 Experience Modifiers: 1.0000 5/01/2005 Make checks payable 200.00 .00 to Preferred Governmental Insuran Page 2