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

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-AK-305-22-103 06/24/2022 07/21/2022 On Receipt San Felipe Frydek V.F.D.

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


Updated
July 20, 2022 @ 5:57 pm

Invoice updated by Geoffrey.

Status Update
July 20, 2022 @ 5:57 pm

Status changed: Draft to Pending.

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