Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Andrew Kerley
1850 Chapman Rd
GoodWater, AL 35072
POLICY# 5713429-B07-01

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
AL-01-712-23-65-E 05/12/2023 05/15/2023 On Receipt Millerville VFD

Product
Price
Qty
Amount
  1. 405 Medical Extrication – Lvl 1

    Patient

    Lilly Adams
    1850 Chapman Rd
    GoodWater, AL 35072

    $500.00
    1
    $500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 72757 Hwy 9- Ashland, AL

Subtotal $500.00
Total Due $500.00


Updated
May 15, 2023 @ 11:30 am

Invoice updated by Geoffrey.

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