Bill To:


Home State County Mutual Insurance
P.O. Box 8036
Waco, TX 76714-8036

Services Rendered To:


Fabian Mundoza
103 CR 921
Angleton, TX 77515
POLICY# 00058595

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BB-326-23-27-E 02/26/2023 06/09/2023 On Receipt Rosharon VFD

Product
Price
Qty
Amount
  1. 406 Medical Extrication – Lvl 2

    Patient

    Josefina Rodrigo Santa Cruz
    3 Burke Ct
    Jones Creek, TX 77541
    POLICY# 967586493

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 288- Rosharon, TX

Subtotal $1,500.00
Total Due $1,500.00


Updated
June 9, 2023 @ 12:47 pm

Invoice updated by Geoffrey.