Bill To:

American Family Mutual Insurance Company
6000 American Parkway
Madison, WI 53738

Services Rendered To:

Elaine Steen
Ibera, Missouri 65486
POLICY # 2439-4075-10-71-FPPA-MO


Product
Price
Qty
Amount

  1. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1
    $150.00

  2. 331 Air Bags (# Used)

    $150.00
    2
    $300.00

  3. 218 Cervical Collar (# Used)

    $25.00
    3
    $75.00

  4. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  5. 402 Fire/Police Services (Per Hour)    

    $100.00
    1
    $100.00

  6. 206 Latex Gloves (Pairs Used)

    $2.00
    14
    $28.00

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

    $100.00
    1
    $100.00

  8. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00

  9. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  10. 408 Air Medical Landing Zone (Used)

    $250.00
    1
    $250.00

    11. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 2004 Highway 42 - Brumley, MO

Subtotal $1,528.00
Total Due $1,528.00
Total Payments Received $1,528.00
Balance $0.00


Checks Payable To:

Sure Fire Recovery Service, LLC
9711 S Mason Road 125-120
Richmond, TX 77407
Federal Tax ID – 83-4417185


  Please Include Incident Number On All Correspondence.

Updated
September 14, 2022 @ 8:39 pm

Invoice updated by Geoffrey.

Status Update
September 14, 2022 @ 8:39 pm

Status changed: Draft to Pending.

Status Update
December 29, 2022 @ 11:52 am

Status changed: Pending to Paid.

Payment
December 29, 2022 @ 4:52 pm

Admin Payment
Payment Total: $1,528.00