Bill To:


Old American County Mutual
P.O. Box 793747
Dallas, TX 75379

Services Rendered To:


Tara Dulaney
3736 FM 1818
Zavalla, TX 75941
Policy # TEJ01904926-00


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

    $300.00
    1
    $300.00
  2. 310 Hydraulic Tool (# Used)

    $200.00
    2
    $400.00
  3. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  5. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Highway 69 South and FM 1818- Zavalla, Texas

Subtotal $1,062.00
Total Due $1,062.00


Updated
March 8, 2022 @ 2:12 pm

Invoice updated by Geoffrey.

Status Update
March 8, 2022 @ 2:12 pm

Status changed: Draft to Pending.

Viewed
October 23, 2022 @ 1:04 am

Invoice viewed by 64.124.8.45 for the first time.