Bill To:


Liberty County Mutual
175 Berkeley Street
Boston, MA 02116

Services Rendered To:


Thomas Dahl
8970 FM 678
Whitesboro, TX 76273
POLICY# ABT-291-835785-40 3 3

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CW-201-23-3188 10/26/2023 10/30/2023 On Receipt Callisburg V.F.D.

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

    $500.00
    1
    $500.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1
    $200.00
  3. 301 Hand Tool (# Used)

    $15.00
    2
    $30.00
  4. 303 SCBA Breathing Apparatus (# Used)

    $50.00
    2
    $100.00
  5. 304 SCBA Cylinder (# Used)

    $25.00
    2
    $50.00
  6. 306 Hose Per 50′ (Amt Used)

    $25.00
    3
    $75.00

  7. Additional Incident Info

    Incident Type: Vehicle Fire Response

    Incident Location: 8970 FM 678 Whitesboro, TX 76273

    Ordinance Info: City Of Callisburg Resolution

Subtotal $955.00
Total Due $955.00


Updated
October 30, 2023 @ 10:34 am

Invoice updated by Geoffrey.

Status Update
October 30, 2023 @ 10:34 am

Status changed: Draft to Pending.