Bill To:


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

Services Rendered To:


Stevens Transport
9757 Military Pkwy
Dallas, TX 75227
POLICY# TEP00001X

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TN-76-821-24-22 04/12/2024 04/16/2024 On Receipt Paint Rock FD

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

    $500.00
    3.25
    $1,625.00
  2. 301 Hand Tool (# Used)

    $15.00
    3
    $45.00
  3. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    3.25
    $325.00
  4. 323 Portable Radio (# Used)

    $10.00
    2
    $20.00

  5. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Buffalo Rd Smith Creek- Onieda, TN

Subtotal $2,015.00
Total Due $2,015.00


Updated
April 16, 2024 @ 9:40 am

Invoice updated by Geoffrey.

Status Update
April 16, 2024 @ 9:40 am

Status changed: Draft to Pending.