Bill To:


MGA INSURANCE COMPANY
3333 Lee Parkway Suite 1200 PO Box 199023
Dallas, TX 75219

Services Rendered To:


Tommy Lozano
224 Marion Dr
Weatherford, TX 76082
POLICY# 03MGEM384813

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-WB-206-23-487 04/24/2022 12/12/2023 On Receipt Briar-Reno Fire Department

Product
Price
Qty
Amount
  1. 103 Rescue Response (Per Hour)

    $400.00
    1
    $400.00
  2. 418 Environmental Hazard Cleanup/Removal

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

    $2.00
    4
    $8.00
  4. 301 Hand Tool (# Used)

    $15.00
    2
    $30.00
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  6. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  7. 322 Turn Out Gear / PPE (Per FireFighter)

    $250.00
    2
    $500.00
  8. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  9. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 12450 FM 730 N- Azle, TX

    Ordinance Info: Briar Reno Cost Recovery Ordinance

Subtotal $1,563.00
Total Due $1,563.00


Updated
December 12, 2023 @ 12:30 pm

Invoice updated by Geoffrey.

Status Update
December 12, 2023 @ 12:30 pm

Status changed: Draft to Pending.