Bill To:


Old American County Mutual
P.O. Box 793747
Dallas, TX 75379

Services Rendered To:


Tyler Goertz
1407 Bernard St Apt 128
Denton, TX 76201
POLICY# 15TX5983816

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CW-201-467485-A 07/05/2022 11/28/2022 On Receipt Callisburg VFD

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

    $350.00
    1
    $350.00
  2. 209 Extinguisher (# Used)

    $50.00
    1
    $50.00
  3. 402 Fire/Police Services (Per Hour)    

    $100.00
    1
    $100.00
  4. 204 Flate (# Used)

    $8.00
    4
    $32.00
  5. 301 Hand Tool (# Used)

    $15.00
    2
    $30.00
  6. 201 Oil Absorbent Material (# Used)

    $35.00
    1
    $35.00
  7. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  8. 306 Hose Per 50′ (Amt Used)

    $25.00
    1
    $25.00

  9. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 8207 E Hwy 82- Gainesville, TX

Subtotal $722.00
Total Due $722.00


Updated
November 28, 2022 @ 11:36 am

Invoice updated by Geoffrey.

Status Update
November 28, 2022 @ 11:36 am

Status changed: Draft to Pending.