Bill To:


Acuity A Mutual Insurance
2800 S. Taylor Drive
Sheboygan, WI 53081

Services Rendered To:


Dante Wilson
14505 Benjamin Franklin Dr
Manor, TX 78653
POLICY# ZQ2782

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-23-2033 12/09/2023 12/12/2023 On Receipt Sam Bass Fire Department

Product
Price
Qty
Amount
  1. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1.75
    $350.00
  2. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1.75
    $437.50
  3. 309 Power Tool (# Used)

    $50.00
    1
    $50.00
  4. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  5. 404 Scene Lighting (Per Hour)

    $75.00
    1.75
    $131.25
  6. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.75
    $175.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 3500 Block of Hwy 45- Austin, TX

    Ordinance Info: Sam Bass Fire Dept. Resolution

Subtotal $1,158.75
Total Due $1,158.75


Updated
December 12, 2023 @ 11:09 am

Invoice updated by Geoffrey.

Status Update
December 12, 2023 @ 11:09 am

Status changed: Draft to Pending.