Bill To:


United Security Health & Cas.
6640 S Cicero Ave
Bedford Park, IL 60638

Services Rendered To:


Willie Washington
608 Louisiana St
Texarkana, AR 71854
POLICY# UAR748660-02

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BY-205-23-904 09/04/2023 09/11/2023 On Receipt Douglassville V.F.D.

Product
Price
Qty
Amount
  1. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1.25
    $312.50
  2. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1.25
    $312.50
  3. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  4. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  5. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  6. 408 Air Medical Landing Zone (Used)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: Fire Department Response

    Incident Location: 143 CR 2225- Douglasville, TX

    Ordinance Info: Douglassville Volunteer Fire Dept. Resolution

Subtotal $1,165.00
Total Due $1,165.00


Updated
September 11, 2023 @ 5:26 pm

Invoice updated by Geoffrey.

Status Update
September 11, 2023 @ 5:26 pm

Status changed: Draft to Pending.

Updated
September 12, 2023 @ 7:37 pm

Invoice updated by Sherryf.

Viewed
September 12, 2023 @ 7:38 pm

Invoice viewed by Sherry Fels (Sherryf) for the first time.

Updated
September 12, 2023 @ 7:40 pm

Invoice updated by Sherryf.