Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Julie Yost
10613 Landsdowne Ln
Rowlett, TX 75089
POLICY# 541 1299-C23-43C

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CN-310-24-3761 05/23/2024 05/28/2024 On Receipt Lavon VFD

Product
Price
Qty
Amount
  1. 101 Aerial/Ladder Response (Per Hour)

    $550.00
    1
    $550.00
  2. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  3. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00
  4. 402 Fire/Police Services (Per Hour)    

    $100.00
    1
    $100.00
  5. 206 Latex Gloves (Pairs Used)

    $2.00
    8
    $16.00
  6. 301 Hand Tool (# Used)

    $15.00
    2
    $30.00
  7. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  8. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  9. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: N St Hwy 78- Lavon, TX

    Ordinance Info: City of Lavon Resolution NO. 2020-03-01

Subtotal $1,321.00
Total Due $1,321.00


Updated
May 28, 2024 @ 1:01 pm

Invoice updated by Geoffrey.

Status Update
May 28, 2024 @ 1:01 pm

Status changed: Draft to Pending.