Bill To:


ALLSTATE PIP / MED PAY
PO BOX 2874
CLINTON, IA 52733-2874

Services Rendered To:


Suzanne Holloway
620 West FM 6
Nevada, Texas 75173
Policy # 000000416292283

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CN-310-2021-187-E 05/03/2021 05/18/2021 On Receipt Lavon V.F.D.

Product
Price
Qty
Amount
  1. 406 Medical Extrication – Lvl 2

    Patient:

    Judy Holloway
    620 West FM 6
    Nevada, Texas 75173

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Highway 78 & Lake Road - Lavon, Texas

Subtotal $1,500.00
Total Due $1,500.00


Updated
May 17, 2021 @ 6:56 pm

Invoice updated by Geoffrey.

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