Bill To:


GEICO INSURANCE – MEDICAL
ONE GEICO BLVD
FREDERICKSBURG, VA 22412-9000

Services Rendered To:


Jayesh Gujar
8100 Memorial Lane #8103
Plano, Texas 75024
Policy # 6051986906


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

    Patient:

    Jayesh Gujar
    8100 Memorial Lane #8103
    Plano, Texas 75024
    Policy # 6051986906

    $500.00
    1
    $500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: MM 224 Northbound on Interstate 45 - Angus, TX

    Ordinance Info: City of Angus Billing Authorization # 7

Subtotal $500.00
Total Due $500.00


Updated
June 3, 2021 @ 12:39 pm

Invoice updated by Geoffrey.