Bill To:


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

Services Rendered To:


Rebeka Simocs, Seraviva
4009 Mocha Trail
Austin, TX 78726
POLICY# YGAO-571910

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-23-839 05/28/2023 05/30/2023 On Receipt Sam Bass Fire Department

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

    $350.00
    1.25
    $437.50
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1.25
    $187.50
  3. 205 Foam (Per Gallon)

    $65.00
    1
    $65.00
  4. 301 Hand Tool (# Used)

    $15.00
    3
    $45.00
  5. 303 SCBA Breathing Apparatus (# Used)

    $50.00
    2
    $100.00
  6. 304 SCBA Cylinder (# Used)

    $25.00
    2
    $50.00
  7. 207 Wetting Agent (Amt Used)

    $25.00
    1
    $25.00
  8. 306 Hose Per 50′ (Amt Used)

    $25.00
    1
    $25.00
  9. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  10. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  11. Additional Incident Info

    Incident Type: Vehicle Fire Response

    Incident Location: 14000 Block of Hwy 45- Round Rock, TX

Subtotal $1,285.00
Total Due $1,285.00


Updated
May 30, 2023 @ 11:14 am

Invoice updated by Geoffrey.

Status Update
May 30, 2023 @ 11:14 am

Status changed: Draft to Pending.

Viewed
March 29, 2024 @ 8:29 pm

Invoice viewed by 66.249.72.5 for the first time.