Bill To:


Sea Harbor Insurance
PO Box 796249
Dallas, TX 75379

Services Rendered To:


Jose Melgar Crispen
121 Aguilar Dr
Hutto, TX 78634
POLICY# SH518471

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-23-1162 07/28/2023 07/31/2023 On Receipt Sam Bass Fire Department

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

    $500.00
    1
    $500.00
  2. 102 Engine Response (Per Hour)

    $500.00
    1
    $500.00
  3. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1
    $200.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  5. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  6. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 1431 & Mayfield Ranch- Round Rock, TX

    Ordinance Info: Sam Bass Fire Dept. Resolution

Subtotal $1,800.00
Total Due $1,800.00


Updated
July 31, 2023 @ 12:10 pm

Invoice updated by Geoffrey.

Status Update
July 31, 2023 @ 12:10 pm

Status changed: Draft to Pending.