Bill To:


MGA INSURANCE COMPANY
3333 Lee Parkway Suite 1200 PO Box 199023
Dallas, TX 75219

Services Rendered To:


Lisa Ray
908 W. Bond Rd
Denison, TX 75020
POLICY# 03MGEP1610640

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CW-201-23-3055 05/11/2023 05/11/2023 On Receipt Callisburg V.F.D.

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

    $350.00
    1
    $350.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  5. 323 Portable Radio (# Used)

    $10.00
    4
    $40.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: CR 103 & CR 106- Whitesboro, TX

    Ordinance Info: City Of Callisburg Resolution

Subtotal $898.00
Total Due $898.00


Updated
May 11, 2023 @ 1:05 pm

Invoice updated by Geoffrey.

Status Update
May 11, 2023 @ 1:05 pm

Status changed: Draft to Pending.