Bill To:


Old American Indemnity
P.O. Box 793747
Dallas, TX 75379

Services Rendered To:


Brent Tripp
18177 W 796 Rd Apt# 28D
Tahlequah, OK 74464
POLICY# 11665


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

    $500.00
    1
    $500.00
  2. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  3. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  4. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: I-40 EB- Henryetta, OK

    Ordinance Info: Tiger Mountain - McIntosh County Resolution 72021

Subtotal $783.00
Total Due $783.00


Updated
March 26, 2024 @ 12:54 pm

Invoice updated by Geoffrey.

Status Update
March 26, 2024 @ 12:54 pm

Status changed: Draft to Pending.