Bill To:


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

Services Rendered To:


David Evans
1311 Sherman Drive
Whitesboro, Texas 76273
Policy # 469-8335-E11-43B-001

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CW-201-2021-431467 06/14/2021 06/23/2021 On Receipt Callisburg V.F.D.

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

    $350.00
    1
    $350.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    2
    $4.00
  4. 404 Scene Lighting (Per Hour)

    $75.00
    1
    $75.00
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: CR 109 & CR 132 - Gainesville, Texas

Subtotal $929.00
Total Due $929.00


Updated
June 22, 2021 @ 1:35 pm

Invoice updated by Geoffrey.

Status Update
June 22, 2021 @ 1:35 pm

Status changed: Draft to Pending.

Viewed
July 12, 2021 @ 12:49 pm

Invoice viewed by Karen Smith (KarenS) for the first time.

Viewed
October 24, 2022 @ 7:24 am

Invoice viewed by 64.124.8.45 for the first time.