Bill To:

Old American County Mutual
P.O. Box 793747
Dallas, TX 75379

Services Rendered To:

Tara Dulaney
3736 FM 1818
Zavalla, TX 75941
Policy # TEJ01904926-00


Product
Price
Qty
Amount

  1. 406 Medical Extrication – Lvl 2

    Patient:

    Tara Dulaney
    3736 FM 1818
    Zavalla, TX 75941
    Policy # TEJ01904926-00

    $1,500.00
    1
    $1,500.00

    2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Highway 69 South and FM 1818- Zavalla, Texas

Subtotal $1,500.00
Total Due $1,500.00


Checks Payable To:

Sure Fire Recovery Service, LLC
9711 S Mason Road 125-120
Richmond, TX 77407
Federal Tax ID – 83-4417185


  Please Include Incident Number On All Correspondence.
Updated
March 8, 2022 @ 2:17 pm

Invoice updated by Geoffrey.

Updated
March 8, 2022 @ 2:17 pm

Invoice updated by Geoffrey.

Updated
March 8, 2022 @ 2:18 pm

Invoice updated by Geoffrey.