Bill To:

Burkhart Insurance
16 North 1st Street
Vincennes, IN 47591

Services Rendered To:

Oak Ridge Farms, LLC
17499 N. CR 1275 E. Street
Meinrad, IN 47577
Policy # CPIN0560117357


Product
Price
Qty
Amount

  1. 406 Medical Extrication – Lvl 2

    Patient:

    Selene Lozano
    510 S. Morris Street
    Gainesville, Texas 76240

    $1,500.00
    1
    $1,500.00

    2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: US Highway 82 - Cooke County, Texas

Subtotal $1,500.00
Total Due $1,500.00


Checks Payable To:

Sure Fire Recovery Service, LLC
9711 S Mason Road 125-120
Richmond, TX 77407
Federal Tax ID – 83-4417185


  Please Include Incident Number On All Correspondence.
Updated
December 21, 2021 @ 3:42 pm

Invoice updated by Geoffrey.

Updated
June 15, 2022 @ 4:28 pm

Invoice updated by Geoffrey.