Bill To:


State Farm Insurance
One State Farm Plaza
Bloomington, IL 61710

Services Rendered To:


Monica Stephenson
Policy # 440279960543 001

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-SH-14-2020-766 01/10/2021 01/13/2021 On Receipt Richland V. F. D.

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

    $350.00
    1
    $350.00
  2. 103 Rescue Response (Per Hour)

    $300.00
    1
    $300.00
  3. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  5. 409 Manpower (Per Hour)

    $50.00
    2
    $100.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Southbound Rest Area - Richland, Texas

Subtotal $1,100.00
Total Due $1,100.00


Updated
January 12, 2021 @ 4:53 pm

Invoice updated by Geoffrey.

Status Update
January 12, 2021 @ 4:53 pm

Status changed: Draft to Pending.

Updated
February 14, 2022 @ 2:20 pm

Invoice updated by Geoffrey.

Viewed
October 25, 2022 @ 5:35 pm

Invoice viewed by 64.124.8.36 for the first time.