Bill To:


STATE FARM MUTUAL INSURANCE
ONE STATE FARM PLAZA
BLOOMINGTON, IL 61710-0001

Services Rendered To:


Joseph Allen Epps
State Farm Mutual
POLICY # 536 6039-H07-43 002


Product
Price
Qty
Amount
  1. 405 Medical Extrication – Lvl 1

    Patient:

    Joseph Allen Epps
    State Farm Mutual
    POLICY # 536 6039-H07-43 002

    $500.00
    1
    $500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Crawford Street & Big Indian Road - Gainesville, Texas

Subtotal $500.00
Total Due $500.00


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