Bill To:


OKLAHOMA FARM BUREAU MUTUAL INSURANCE COMPANY
2501 N Stiles Ave,
Oklahoma City, OK 73105

Services Rendered To:


Samantha Hubler
9707 E 73rd St S
Braggs, OK 74423
POLICY# 09852419

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-49-015-23-6 06/10/2023 06/13/2023 On Receipt Tiger Mountain Fire Dept.

Product
Price
Qty
Amount
  1. 103 Rescue Response (Per Hour)

    $500.00
    1
    $500.00
  2. 102 Engine Response (Per Hour)

    $500.00
    1
    $500.00
  3. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00

  4. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: IH 40 WB- Henryetta, OK

    Ordinance Info: McIntosh County Resolution 72021

Subtotal $1,100.00
Total Due $1,100.00


Updated
June 13, 2023 @ 1:49 pm

Invoice updated by Geoffrey.

Status Update
June 13, 2023 @ 1:49 pm

Status changed: Draft to Pending.