Bill To:


Arch Insurance Group Claims Department
P.O. Box 542033
Omaha, NE 68154

Services Rendered To:


Policy# ZACAT7002902
Daniel Rose
1105 Baker Rd.
Albertville, AL 35951

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
AL-50-022-22-1529-A-E 12/11/2022 01/17/2023 On Receipt AL-50-022-22-1529-A-E

Product
Price
Qty
Amount
  1. 331 Air Bags (# Used)

    $150.00
    1
    $150.00
  2. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  4. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  5. 405 Medical Extrication – Lvl 1

    $500.00
    1
    $500.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Hustleville Rd. & Rice Mill Chaviers- Albertville, AL 35951

Subtotal $937.00
Total Due $937.00