Bill To:


ALLSTATE PIP / MED PAY
PO BOX 2874
CLINTON, IA 52733-2874

Services Rendered To:


Christopher Hamon
8601 NW 155th Place
Edmond, OK 73013
Driver: Ashlen Grace
POLICY # 000000821129149

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-16-016-22-551-E 08/21/2022 08/24/2022 On Receipt Wichita Mountain Estates V.F.D.

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

    Patient:

    Ashlen Grace
    8601 NW 155th Place
    Edmond, OK 73013

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Interstate 44 @ MM 43 - Lawton, OK

Subtotal $1,500.00
Total Due $1,500.00


Updated
August 24, 2022 @ 2:59 pm

Invoice updated by Geoffrey.

Viewed
October 3, 2022 @ 7:59 pm

Invoice viewed by Karen Meder - Smith (KarenS) for the first time.

Viewed
October 23, 2022 @ 12:01 am

Invoice viewed by 64.124.8.29 for the first time.