Bill To:


Trisura Insurance
210 Park Avenue, Suite 1300
Oklahoma City, OK 73102

Services Rendered To:


Juan Cervantes
5724 Calmar Dr Apt# 4B
Montgomery, AL 36116
POLICY# ALC30005289

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
AL-01-403-24-347 04/13/2024 04/16/2024 On Receipt Jemison FD

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. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00
  7. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  8. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 12367 CR 42- Jemison, AL

Subtotal $1,458.00
Total Due $1,458.00


Updated
April 16, 2024 @ 9:51 am

Invoice updated by Geoffrey.

Status Update
April 16, 2024 @ 9:51 am

Status changed: Draft to Pending.