Bill To:


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

Services Rendered To:


Debbie Fitzgerald
Dodge Charger 2015
License Plate# PGL9828
POLICY# 15TX6041941

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-AZ-409-23-93-E 08/27/2023 09/25/2023 On Receipt Valley Mills V.F.D.

Product
Price
Qty
Amount
  1. 406 Medical Extrication – Lvl 2

    Patient

    James Burgoon

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 11996 Hwy 6- Crawford, TX 76638

Subtotal $1,500.00
Total Due $1,500.00


Updated
September 25, 2023 @ 2:17 pm

Invoice updated by Geoffrey.