Bill To:


American Family Connect Property and Casualty
3500 Packerland Drive
Depere, WI 54115

Services Rendered To:


Kerisha Rodney
602 Chuckwagon
Josephine, TX 75173
POLICY# AI04262435

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CN-310-23-153 03/13/2023 03/14/2023 On Receipt Lavon V.F.D.

Product
Price
Qty
Amount
  1. 101 Aerial/Ladder Response (Per Hour)

    $400.00
    1
    $400.00
  2. 402 Fire/Police Services (Per Hour)    

    $100.00
    1
    $100.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  4. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  6. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1
    $150.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: CR 541- Lavon, TX

    Ordinance Info: City of Lavon Resolution NO. 2020-03-01

Subtotal $1,012.00
Total Due $1,012.00


Updated
March 14, 2023 @ 10:24 am

Invoice updated by Geoffrey.

Status Update
March 14, 2023 @ 10:24 am

Status changed: Draft to Pending.