Bill To:


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

Services Rendered To:


Chastity Daniels
231 E S Boundry
Walters, OK 73572
Policy # 366-5986-F19-36B

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-16-016-2021-126 05/15/2021 05/26/2021 On Receipt Wichita Mountain Estates V.F.D.

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

    $350.00
    2.75
    $962.50
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    2.75
    $412.50
  3. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  4. 202 Oil Absorbent Sheet (# Used)

    $2.50
    2
    $5.00
  5. 203 Oil Boom (# Used)

    $20.00
    1
    $20.00
  6. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    2.75
    $275.00
  7. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  8. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: I-44 Eastbound - Lawton, OK

Subtotal $2,175.00
Total Due $2,175.00


Updated
May 25, 2021 @ 6:05 pm

Invoice updated by Geoffrey.

Status Update
May 25, 2021 @ 6:05 pm

Status changed: Draft to Pending.

Viewed
October 24, 2022 @ 1:57 am

Invoice viewed by 64.124.8.25 for the first time.