Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Joshua Hatten
30800 Oakstream Ln
Lebanon, MO 65536
POLICY# 68671C4D07-25

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
MO-05-307-23-83 05/20/2023 05/22/2023 On Receipt Eldridge V.F.D.

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

    $350.00
    1.75
    $612.50
  2. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  3. 306 Hose Per 50′ (Amt Used)

    $25.00
    3
    $75.00
  4. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 30800 Oakstream Ln- Lebanon, MO

Subtotal $949.50
Total Due $949.50


Updated
May 22, 2023 @ 10:57 am

Invoice updated by Geoffrey.

Status Update
May 22, 2023 @ 10:57 am

Status changed: Draft to Pending.

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