Bill To:


American Family Mutual Insurance Company
6000 American Parkway
Madison, WI 53738

Services Rendered To:


Samantha Mills
282 Elm Spring Rd
Iberia, MO 65486
POLICY# 0977-4097-08

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
MO-06-607-23-3213 05/06/2023 06/09/2023 On Receipt Brumley Fire Protection District

Product
Price
Qty
Amount
  1. 102 Engine Response (Per Hour)

    $350.00
    1
    $350.00
  2. 402 Fire/Police Services (Per Hour)    

    $100.00
    1
    $100.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  5. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 1956 Hwy 42- Brumley, MO

Subtotal $583.00
Total Due $583.00


Updated
June 9, 2023 @ 1:01 pm

Invoice updated by Geoffrey.

Status Update
June 9, 2023 @ 1:01 pm

Status changed: Draft to Pending.