Bill To:


Home State County Mutual Insurance
P.O. Box 8036
Waco, TX 76714-8036

Services Rendered To:


Linette Payan
20522 Benford Ridge Ln
Cypress, TX 77433
POLICY# 2016816797

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BB-326-22-255 12/10/2022 06/09/2023 On Receipt Rosharon VFD

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

    $350.00
    1
    $350.00
  2. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1
    $150.00

  3. Additional Incident Info

    Incident Type: Vehicle Fire Response

    Incident Location: 288 SB- Rosharon, TX

Subtotal $500.00
Total Due $500.00


Updated
June 9, 2023 @ 12:20 pm

Invoice updated by Geoffrey.

Status Update
June 9, 2023 @ 12:20 pm

Status changed: Draft to Pending.