Bill To:


Loya Insurance Company
P.O. Box 972450
El Paso, TX 79997

Services Rendered To:


Randy Lemmon
Shauna Dr
Ft Worth, TX 76130
POLICY# 788-6862828

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-49-015-23-682 11/03/2023 11/07/2023 On Receipt Tiger Mountain Fire Dept.

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

    $500.00
    3
    $1,500.00
  2. 104 Tanker Response (Per Hour)

    $400.00
    3
    $1,200.00
  3. 301 Hand Tool (# Used)

    $15.00
    3
    $45.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    3
    $300.00

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: I-40 E MM 246- Henryetta, OK

    Ordinance Info: Tiger Mountain - McIntosh County Resolution 72021

Subtotal $3,045.00
Total Due $3,045.00


Updated
November 7, 2023 @ 7:54 am

Invoice updated by Geoffrey.

Status Update
November 7, 2023 @ 7:54 am

Status changed: Draft to Pending.