Bill To:


State Farm Insurance
One State Farm Plaza
Bloomington, IL 61710

Services Rendered To:


Cobalt Kiser - Driver
Brad Kiser - Owner
11252 Upper State Line Road
Vivian, LA 71082
Policy # 4328580A0743

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BY205-2019-1031 10/31/2019 11/06/2019 On Receipt Douglassville Volunteer Fire Department

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

    $350.00
    2
    $700.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    2
    $300.00
  3. 301 Hand Tool (# Used)

    $15.00
    3
    $45.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    2
    $200.00
  5. 104 Tanker Response (Per Hour)

    $300.00
    1
    $300.00
  6. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: State Hwy 8, Cass County Texas

Subtotal $1,795.00
Total Due $1,795.00
Updated
November 6, 2019 @ 2:22 pm

Invoice updated by Karen Smith.

Status Update
November 6, 2019 @ 2:22 pm

Status changed: Draft to Pending.

Updated
November 6, 2019 @ 2:25 pm

Invoice updated by Karen Smith.

Viewed
October 22, 2022 @ 2:31 pm

Invoice viewed by 64.124.8.25 for the first time.