Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Sally Thompson McCommon
17088 Faircrest Dr
Whitney, TX 76692
POLICY# 157 4084-F10-43J 001

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-KP-401-22-141-B 08/17/2022 03/28/2023 On Receipt Peoria V.F.D.

Product
Price
Qty
Amount
  1. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1.25
    $187.50
  2. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1.25
    $187.50
  3. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  4. 206 Latex Gloves (Pairs Used)

    $2.00
    20
    $40.00
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.25
    $125.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: State Hwy 22 & Hcr 2421 E- Hillsboro, TX

    Ordinance Info: Recovery of Service Costs for Peoria VFD

Subtotal $1,040.00
Total Due $1,040.00


Updated
March 28, 2023 @ 3:01 pm

Invoice updated by Geoffrey.

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