Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Ryan Anthony Rivas
POLICY# 373 7411 B29-53E 003

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BB-326-24-94 05/13/2024 05/28/2024 On Receipt Rosharon VFD

Product
Price
Qty
Amount
  1. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1.25
    $250.00
  2. 102 Engine Response (Per Hour)

    $500.00
    1.25
    $625.00
  3. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1.25
    $312.50
  4. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1.25
    $312.50
  5. 103 Rescue Response (Per Hour)

    $400.00
    1.25
    $500.00
  6. 301 Hand Tool (# Used)

    $15.00
    7
    $105.00
  7. 206 Latex Gloves (Pairs Used)

    $2.00
    8
    $16.00
  8. 324 Traffic Cone (# Used)

    $5.00
    20
    $100.00
  9. 309 Power Tool (# Used)

    $50.00
    2
    $100.00

  10. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Fm 521- Rosharon, TX

    Ordinance Info: Rosharon Cost Recovery Resolution

Subtotal $2,321.00
Total Due $2,321.00


Updated
May 28, 2024 @ 1:20 pm

Invoice updated by Geoffrey.

Status Update
May 28, 2024 @ 1:20 pm

Status changed: Draft to Pending.