Bill To:


PROGRESSIVE INSURANCE
6300 WILSON MILLS ROAD
MAYFIELD VILLAGE, OH 44143-2109

Services Rendered To:


Gary Allen
15824 CR 4060
Scurry, Texas 75158
Policy # 910852306

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-SH-14-2021-05872 03/27/2021 04/08/2021 On Receipt Richland Volunteer Fire Department

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

    $350.00
    1
    $350.00
  2. 310 Hydraulic Tool (# Used)

    $200.00
    1
    $200.00
  3. 413 Fire Department Response Fee – Lvl 4

    Patient Entrapment

    $500.00
    1
    $500.00
  4. 701 Body Removal (Per Body)  

      

    $250.00
    1
    $250.00

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: I-45 North @ 227 - Angus, Texas

    Ordinance Info: Richland Billing Ordinance NO. 170 Cost Recovery

Subtotal $1,300.00
Total Due $1,300.00


Updated
April 7, 2021 @ 11:37 pm

Invoice updated by Geoffrey.

Status Update
April 7, 2021 @ 11:37 pm

Status changed: Draft to Pending.

Updated
April 7, 2021 @ 11:38 pm

Invoice updated by Geoffrey.

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