Bill To:


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

Services Rendered To:


Derrick Lee Kossaeth
3264 Weil Road
Marion, Texas 78124
Policy # 364 5533-A22-53B 002

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-HS-403-2021-142-A 03/31/2021 04/01/2021 On Receipt McQueeney V.F.D.

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

    $300.00
    1
    $300.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  3. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  4. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  5. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  6. 201 Oil Absorbent Material (# Used)

    $35.00
    1
    $35.00
  7. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  8. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  9. 324 Traffic Cone (# Used)

    $5.00
    10
    $50.00
  10. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  11. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 7748 FM 725 - McQueeney, Texas

    Ordinance Info: McQueeney Cost Recovery Resolution

Subtotal $1,187.00
Total Due $1,187.00


Updated
March 31, 2021 @ 4:02 pm

Invoice updated by Geoffrey.

Status Update
March 31, 2021 @ 4:02 pm

Status changed: Draft to Pending.

Viewed
June 24, 2021 @ 5:17 pm

Invoice viewed by Karen Smith (KarenS) for the first time.