Bill To:


GREAT WEST CASUALTY
1100 WEST 29th STREET
SOUTH SOUIX CITY, NE 68776-3130

Services Rendered To:


Groendyke Transport
2510 Rock Island Blvd
Enid, OK 73701
Policy # GWP37571P

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-59-007-22-33-EE 03/09/2022 05/16/2022 On Receipt North 48 Fire Department

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

    Patient:

    David Tilley

    3603 S. New Haven 

    Tulsa, OK 74135

    $500.00
    1
    $500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Highway 412 Cimarron Turnpike @ MM 54 - Terlton, Oklahoma

Subtotal $500.00
Total Due $500.00


Updated
May 15, 2022 @ 3:03 pm

Invoice updated by Geoffrey.