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

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-AC-309-22-34-E 03/02/2022 03/08/2022 On Receipt Zavalla Fire Department

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


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.

Viewed
October 24, 2022 @ 1:38 pm

Invoice viewed by 64.124.8.26 for the first time.