Bill To:


UNITED SPECIALTY INSURANCE
PO BOX 24622
FORT WORTH, TX 76124-1622

Services Rendered To:


Debra Johnson
3601 Granddaughter Lane, Lot 23
Harrah, OK 73045

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-55-024-22-005 01/12/2022 01/25/2022 On Receipt Newalla Fire Department

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

    $300.00
    1.25
    $375.00
  2. 206 Latex Gloves (Pairs Used)

    $2.00
    5
    $10.00
  3. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  4. Additional Incident Info

    Incident Type: Fire Department Response

    Incident Location: 3601 Granddaughter Lane, Lot 23 Harrah, OK 73045

Subtotal $635.00
Total Due $635.00


Updated
January 24, 2022 @ 7:37 pm

Invoice updated by Geoffrey.

Status Update
January 24, 2022 @ 7:37 pm

Status changed: Draft to Pending.

Updated
January 24, 2022 @ 7:38 pm

Invoice updated by Geoffrey.

Updated
February 11, 2022 @ 4:41 pm

Invoice updated by Geoffrey.

Updated
February 11, 2022 @ 4:42 pm

Invoice updated by Geoffrey.