Bill To:

Acuity A Mutual Insurance
2800 S. Taylor Drive
Sheboygan, WI 53081

Services Rendered To:

Sealy Concrete Inc.
4460 NE Interstate 10 (Frontage RD)
Sealy, TX 77474
Driver: Wayne Walger
POLICY # ZC7442


Product
Price
Qty
Amount

  1. 102 Engine Response (Per Hour)

    $350.00
    1.25
    $437.50

  2. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00

  3. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  4. 310 Hydraulic Tool (# Used)

    $200.00
    2
    $400.00

  5. 206 Latex Gloves (Pairs Used)

    $2.00
    3
    $6.00

  6. 301 Hand Tool (# Used)

    $15.00
    3
    $45.00

  7. 309 Power Tool (# Used)

    $50.00
    4
    $200.00

  8. 317 Rescue Struts (# Used)

    $50.00
    1
    $50.00

  9. 211 Salvage Cover (Amt Used)           

    $35.00
    2
    $70.00

  10. 404 Scene Lighting (Per Hour)

    $75.00
    1.25
    $93.75

  11. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.25
    $125.00

    12. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 9300 Block of FM 1458 & Ward Bend - San Felipe, Texas

Subtotal $1,702.25
Total Due $1,702.25


Checks Payable To:

Sure Fire Recovery Service, LLC
9711 S Mason Road 125-120
Richmond, TX 77407
Federal Tax ID – 83-4417185


  Please Include Incident Number On All Correspondence.
Updated
July 20, 2022 @ 5:57 pm

Invoice updated by Geoffrey.

Status Update
July 20, 2022 @ 5:57 pm

Status changed: Draft to Pending.