Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Brian Weltz
10307 Pirogue Road
Oil City, LA 71061
Policy # 2363855-B08-18


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

    $350.00
    2.5
    $875.00
  2. 103 Rescue Response (Per Hour)

    $300.00
    2.5
    $750.00
  3. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  4. 409 Manpower (Per Hour)

    $50.00
    4
    $200.00
  5. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: State Highway 77 West @ CR 3319 - Cass County

Subtotal $2,090.00
Total Due $2,090.00


Updated
March 19, 2021 @ 2:14 pm

Invoice updated by Geoffrey.

Status Update
March 19, 2021 @ 2:14 pm

Status changed: Draft to Pending.

Updated
March 19, 2021 @ 2:15 pm

Invoice updated by Geoffrey.

Updated
March 19, 2021 @ 2:20 pm

Invoice updated by Geoffrey.