Bill To:


GREAT WEST CASUALTY
1100 WEST 29th STREET
SOUTH SOUIX CITY, NE 68776-3130

Services Rendered To:


Romy Martinez
117 W Deer Horn Pass
Harker Heights, TX 76548
POLICY# MCP52910E

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-24-993 06/07/2024 06/11/2024 On Receipt Sam Bass FD

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

    $250.00
    1.5
    $375.00
  2. 102 Engine Response (Per Hour)

    $500.00
    1.5
    $750.00
  3. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1.5
    $300.00
  4. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1.5
    $300.00
  5. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  6. 301 Hand Tool (# Used)

    $15.00
    4
    $60.00
  7. 201 Oil Absorbent Material (# Used)

    $35.00
    8
    $280.00
  8. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.5
    $150.00
  9. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  10. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 3 Block SH 45- Austin, TX

    Ordinance Info: Sam Bass Fire Dept. Resolution

Subtotal $2,477.00
Total Due $2,477.00


Updated
June 11, 2024 @ 3:35 pm

Invoice updated by Geoffrey.

Status Update
June 11, 2024 @ 3:35 pm

Status changed: Draft to Pending.