Bill To:


Home State County Mutual Insurance
P.O. Box 8036
Waco, TX 76714-8036

Services Rendered To:


Cheryl Elam
1908 Pelican Drive North
Azle, Texas 76020
Policy # TXA01304575-41

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-WB-440-2020-1104 12/10/2020 12/16/2020 On Receipt Briar-Reno Fire Department

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

    $150.00
    1
    $150.00
  2. 104 Tanker Response (Per Hour)

    $300.00
    1
    $300.00
  3. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  4. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  5. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  6. 201 Oil Absorbent Material (# Used)

    $35.00
    1
    $35.00
  7. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  8. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  9. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  10. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 1524 Sandy Beach Road - Azle/Pelican Bay, Texas

    Ordinance Info: Briar Reno Cost Recovery Amendment

Subtotal $1,268.00
Total Due $1,268.00
Updated
December 15, 2020 @ 1:59 pm

Invoice updated by Geoffrey.

Status Update
December 15, 2020 @ 1:59 pm

Status changed: Draft to Pending.