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


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


Checks Payable To:

Sure Fire Recovery Service, LLC
9711 S Mason Road 125-120
Richmond, TX 77407
Federal Tax ID – 83-4417185


  Please Include Incident Number On All Correspondence.
Updated
May 15, 2022 @ 3:03 pm

Invoice updated by Geoffrey.