Bill To:


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

Services Rendered To:


Daniel Dominguez
1309 WedgeWood Ave
Odessa, TX 79761
POLICY# 467 4411-J23-43B 002

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-SH-201-C23-01506 01/17/2023 02/06/2023 On Receipt Angus VFD

Product
Price
Qty
Amount
  1. 103 Rescue Response (Per Hour)

    $300.00
    2.25
    $675.00
  2. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  3. 211 Salvage Cover (Amt Used)           

    $35.00
    1
    $35.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    2.25
    $225.00
  5. 306 Hose Per 50′ (Amt Used)

    $25.00
    1
    $25.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 224 SB IH 45- Angus, TX

    Ordinance Info: City of Angus Billing Authorization # 7

Subtotal $1,210.00
Total Due $1,210.00


Updated
February 6, 2023 @ 1:22 pm

Invoice updated by Geoffrey.

Status Update
February 6, 2023 @ 1:22 pm

Status changed: Draft to Pending.