Bill To:


Farmers Insurance
PO Box 268993
Oklahoma City, OK 73126

Services Rendered To:


Alice Gibson
Policy # 0191303473
CLAIM # 5011642002-1
ADJUSTER: MERIAM ROMERO

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CW-201-2021-427309-1 04/24/2021 07/30/2021 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
    6
    $12.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  5. 323 Portable Radio (# Used)

    $10.00
    4
    $40.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 12227 East Highway 82 - Gainesville, Texas

Subtotal $652.00
Total Due $652.00


Updated
July 30, 2021 @ 5:23 pm

Invoice updated by Geoffrey.

Updated
July 30, 2021 @ 5:28 pm

Invoice updated by Geoffrey.

Updated
July 30, 2021 @ 5:30 pm

Invoice updated by Geoffrey.

Updated
July 30, 2021 @ 5:30 pm

Invoice updated by Geoffrey.

Updated
December 21, 2021 @ 4:18 pm

Invoice updated by Geoffrey.

Updated
July 12, 2022 @ 5:02 pm

Invoice updated by Geoffrey.

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