Bill To:


American Family Connect Property and Casualty
3500 Packerland Drive
Depere, WI 54115

Services Rendered To:


Maria Crowder
3549 Shiraz Loop
Round Rock, TX 78665
POLICY# AI 03215302

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-23-1054-B 07/08/2023 07/10/2023 On Receipt Sam Bass Fire Department

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

    $500.00
    1
    $500.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

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

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

    $100.00
    1
    $100.00
  5. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Corner Wodd & 620- Round Rock, TX

    Ordinance Info: Sam Bass Fire Dept. Resolution

Subtotal $1,095.00
Total Due $1,095.00


Updated
July 10, 2023 @ 12:49 pm

Invoice updated by Geoffrey.