Bill To:


Liberty Mutual Insurance
175 Berkeley Street
Boston, MA 02116

Services Rendered To:


Policy# ABT-298-017249-40-90
Debra Bledsoe
628 County Rd. 3696
Springtown, TX 76082

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-WB-206-2020-849-B 09/24/2020 09/22/2021 On Receipt Briar-Reno Fire Dept.

Product
Price
Qty
Amount
  1. 104 Tanker Response (Per Hour)

    $300.00
    1
    $300.00
  2. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  4. 404 Scene Lighting (Per Hour)

    $75.00
    1
    $75.00
  5. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  6. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  7. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  8. 322 Turn Out Gear / PPE (Per FireFighter)

    $250.00
    3
    $750.00

  9. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Old Reno Rd. & Tim Hall Rd., Reno/Azle, TX

Subtotal $1,808.00
Total Due $1,808.00


Updated
September 21, 2021 @ 11:46 pm

Invoice updated by Karen Smith.