Bill To:


Consumers County Mutual Insurance
4245 N. Central Expressway, Suite 500
Dallas, TX 75205

Services Rendered To:


Elton Dias
7709 Laramie Blvd
Round Rock, TX 78681
POLICY# 014233302-949H

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-24-729-A 05/01/2024 05/02/2024 On Receipt Sam Bass Fire Department

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

    $500.00
    1
    $500.00
  2. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1
    $250.00
  3. 201 Oil Absorbent Material (# Used)

    $35.00
    1
    $35.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  5. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 17156 RM 620- Round Rock, TX

    Ordinance Info: Sam Bass Fire Dept. Resolution

Subtotal $1,385.00
Total Due $1,385.00


Updated
May 2, 2024 @ 3:09 pm

Invoice updated by Geoffrey.

Status Update
May 2, 2024 @ 3:09 pm

Status changed: Draft to Pending.

Updated
May 2, 2024 @ 3:10 pm

Invoice updated by Geoffrey.