Bill To:


ENCOMPASS – PIP / MEDPAY
PO BOX 2873
CLINTON, IA 52733-2873

Services Rendered To:


Christina Bassetti
325 Warwick Road
Deptford, NJ 08096-6023
Policy # 282570728

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-HS-403-2021-430-EE 09/30/2021 10/08/2021 On Receipt McQueeney V.F.D.

Product
Price
Qty
Amount
  1. 405 Medical Extrication – Lvl 1

    Patient:

    Susie Gunn
    2222 Louise Street
    Sequin, Texas 78155
    Policy # A7999825100

    $500.00
    1
    $500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 78 & FM 1044 - McQueeney, Texas

    Ordinance Info: McQueeney Cost Recovery Resolution 4521

Subtotal $500.00
Total Due $500.00


Updated
October 7, 2021 @ 3:56 pm

Invoice updated by Geoffrey.

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