Bill To:


John David Hale
3641 Waters Edge Dr
Midlothian, TX 76065

Services Rendered To:


John David Hale
3641 Waters Edge Dr
Midlothian, TX 76065
POLICY# 4451766804

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-KP-401-23-46-E 03/10/2023 03/16/2023 On Receipt Peoria V.F.D.

*** YOUR INSURANCE COMPANY HAS SENT YOU PAYMENT FOR FIRE DEPARTMENT SERVICES. PLEASE REMIT THAT PAYMENT TO OUR OFFICE. ***

Product
Price
Qty
Amount
  1. 405 Medical Extrication – Lvl 1

    Patient

    Samantha Hale
    3641 Waters Edge Dr
    Midlothian, TX 76065

    $500.00
    1
    $500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 3500 Block Of St Hwy 22- Hillsboro, TX

    Ordinance Info: Recovery of Service Costs for Peoria VFD

Subtotal $500.00
Total Due $500.00


Updated
March 16, 2023 @ 1:14 pm

Invoice updated by Geoffrey.

Updated
May 9, 2023 @ 10:45 am

Invoice updated by Geoffrey.