Bill To:


Nationwide Insurance
One Nationwide Plaza
Columbus, OH 43215-2220

Services Rendered To:


Karren Harberj
3202 Peruga Ln
Round Rock, TX 78681
POLICY# 7842J166826

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-24-708-B 04/29/2024 04/30/2024 On Receipt Sam Bass FD

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

    $500.00
    1
    $500.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1
    $200.00
  3. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1
    $200.00
  4. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1
    $250.00
  5. 103 Rescue Response (Per Hour)

    $400.00
    1
    $400.00
  6. 301 Hand Tool (# Used)

    $15.00
    3
    $45.00
  7. 201 Oil Absorbent Material (# Used)

    $35.00
    1
    $35.00
  8. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  9. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  10. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Great Oaks & 620- Round Rock, TX

    Ordinance Info: Sam Bass Cost Recovery Resolution

Subtotal $1,980.00
Total Due $1,980.00


Updated
April 30, 2024 @ 12:43 pm

Invoice updated by Geoffrey.