Bill To:


Arch Insurance Group Claims Department
P.O. Box 542033
Omaha, NE 68154

Services Rendered To:


Policy# ZACAT7002902
Daniel Rose
1105 Baker Rd.
Albertville, AL 35951


Product
Price
Qty
Amount
  1. 331 Air Bags (# Used)

    $150.00
    1
    $150.00
  2. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  4. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  5. 405 Medical Extrication – Lvl 1

    $500.00
    1
    $500.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Hustleville Rd. & Rice Mill Chaviers- Albertville, AL 35951

Subtotal $937.00
Total Due $937.00


Updated
January 16, 2023 @ 9:35 pm

Invoice updated by Karen Smith.

Status Update
January 16, 2023 @ 9:35 pm

Status changed: Draft to Pending.