Bill To:


USAA CASUALTY INSURANCE
9800 FREDERICKSBURG ROAD
SAN ANTONIO, TX 78240-4100

Services Rendered To:


Greg Autumn
2013 S. Thomas
Francis, OK 74844
Policyholder: Dylan Gray
Policy # 024876800C7101
Claim # 024876800-002

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-49-015-19-3108 08/31/2019 07/13/2021 On Receipt Tiger Mountain Fire Dept.

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

    $500.00
    1.25
    $625.00
  2. 105 Utility Vehicle Response (Per Hour)

    $500.00
    1.25
    $625.00
  3. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.25
    $125.00
  4. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: I-40 Eastbound @ MM 250 - Henryetta, OK

Subtotal $1,625.00
Total Due $1,625.00


Updated
July 12, 2021 @ 3:26 pm

Invoice updated by Geoffrey.

Status Update
July 12, 2021 @ 3:26 pm

Status changed: Draft to Pending.

Updated
December 28, 2021 @ 6:24 pm

Invoice updated by Geoffrey.

Viewed
October 22, 2022 @ 8:51 pm

Invoice viewed by 64.124.8.32 for the first time.