Bill To:


STATE FARM MUTUAL INSURANCE
ONE STATE FARM PLAZA
BLOOMINGTON, IL 61710-0001

Services Rendered To:


Policy# 011-3680-C29-43Q 001
Gayland Roy Francis
12854 E. Hwy. 82
Whitesboro, TX 76273

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CW-201-23-3045 04/24/2023 04/25/2023 On Receipt Callisburg V.F.D.

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

    $350.00
    1
    $350.00
  2. 201 Oil Absorbent Material (# Used)

    $35.00
    1
    $35.00
  3. 419 Environmental Spill

    $250.00
    1
    $250.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: E. Hwy 82 @ Cooke/Grayson County Line, Whitesboro, TX

    Ordinance Info: City of Callisburg Resolution

Subtotal $735.00
Total Due $735.00


Updated
April 25, 2023 @ 2:19 pm

Invoice updated by Geoffrey.

Status Update
April 25, 2023 @ 2:19 pm

Status changed: Draft to Pending.

Updated
April 25, 2023 @ 2:19 pm

Invoice updated by Geoffrey.