Bill To:


SHELTER INSURANCE
1817 WEST BROADWAY
COLUMBIA, MO 65203-1107

Services Rendered To:


Lujan Gladys
5432 Hollycock Circle
Kingston, OK 73439
Policy # 35-1-010588232-0002

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-49-015-21-1007-003 07/10/2021 07/13/2021 On Receipt Tiger Mountain Fire Dept.

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

    $500.00
    1.75
    $875.00
  2. 105 Utility Vehicle Response (Per Hour)

    $500.00
    1.75
    $875.00
  3. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.75
    $175.00
  5. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  6. 306 Hose Per 50′ (Amt Used)

    $25.00
    2
    $50.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: I-40 Eastbound @ MM 347 - Bridge over Tiger Mtn. Exit - Henryetta, OK

Subtotal $2,240.00
Total Due $2,240.00


Updated
July 12, 2021 @ 6:55 pm

Invoice updated by Geoffrey.

Status Update
July 12, 2021 @ 6:55 pm

Status changed: Draft to Pending.

Updated
July 12, 2021 @ 6:56 pm

Invoice updated by Geoffrey.

Updated
July 12, 2021 @ 6:56 pm

Invoice updated by Geoffrey.

Updated
July 12, 2021 @ 6:58 pm

Invoice updated by Geoffrey.