Bill To:


ALLSTATE INSURANCE
3075 SANDERS ROAD - SUITE H1A
NORTHBROOK, IL 60062-7127

Services Rendered To:


Charlotte Hendricks
303 Chimney Rock
Lufkin, TX 75901
POLICY# 429198317

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-AC-501-24-0241 02/28/2024 03/19/2024 On Receipt Moffett VFD

Product
Price
Qty
Amount
  1. 103 Rescue Response (Per Hour)

    $400.00
    1.5
    $600.00
  2. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1.5
    $375.00
  3. 103 Rescue Response (Per Hour)

    $400.00
    1.5
    $600.00
  4. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  5. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  6. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.5
    $150.00
  7. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  8. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  9. 330 Backboard (# Used)

    $25.00
    1
    $25.00
  10. 219 Blanket (# Used)

    $25.00
    1
    $25.00

  11. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 2021- Lufkin, TX

Subtotal $2,083.00
Total Due $2,083.00


Updated
March 19, 2024 @ 10:15 am

Invoice updated by Geoffrey.

Status Update
March 19, 2024 @ 10:15 am

Status changed: Draft to Pending.