Bill To:


Safeway Insurance
1505 LBJ Freeway, Suite # 170
Dallas, TX 75234

Services Rendered To:


Nathaniel Scott
366 Lake Shore Dr
Shelby, AL 35143
POLICY# 3472152ALPP005

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
AL-01-403-23-826 08/05/2023 10/17/2023 On Receipt Jemison Fire Department

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

    $500.00
    1
    $500.00
  2. 103 Rescue Response (Per Hour)

    $400.00
    1
    $400.00
  3. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  4. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  5. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  7. 408 Air Medical Landing Zone (Used)

    $250.00
    1
    $250.00

  8. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: AL Hwy 155 & CR 127- Montevallo, AL

Subtotal $1,458.00
Total Due $1,458.00


Updated
October 17, 2023 @ 3:09 pm

Invoice updated by Geoffrey.

Status Update
October 17, 2023 @ 3:09 pm

Status changed: Draft to Pending.