Bill To:


Farmers Insurance
PO Box 268993
Oklahoma City, OK 73126

Services Rendered To:


Cindy Shelley
19857 Highway 49, Apt. B
Lawton, OK 73507
Policy # 510464359

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-16-016-2022-224 01/11/2022 01/12/2022 On Receipt Wichita Mountain Estates V.F.D.

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

    $350.00
    1.25
    $437.50
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1.25
    $187.50
  3. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  4. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  5. 313 TIC Thermal Imaging Camera (# Used)

    $100.00
    1
    $100.00
  6. 206 Latex Gloves (Pairs Used)

    $2.00
    2
    $4.00
  7. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  8. 201 Oil Absorbent Material (# Used)

    $35.00
    2
    $70.00
  9. 404 Scene Lighting (Per Hour)

    $75.00
    1.25
    $93.75
  10. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.25
    $125.00
  11. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  12. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: North West Meers Porter Hill Road & Miller Road - Lawton, OK

Subtotal $1,557.75
Total Due $1,557.75


Updated
January 11, 2022 @ 5:20 pm

Invoice updated by Geoffrey.

Status Update
January 11, 2022 @ 5:20 pm

Status changed: Draft to Pending.