Bill To:

PROGRESSIVE INSURANCE – MEDICAL
6300 WILSON MILLS ROAD
MAYFIELD VILLAGE, OH 44143-2109

Services Rendered To:

Salvador Diaz Rivas
163 Forrest Lawn
Wharton, Texas 77488
Policy # 932452966


Product
Price
Qty
Amount

  1. 406 Medical Extrication – Lvl 2

    Patient:

    Salvador Diaz Rivas

    163 Forrest Lawn

    Wharton, Texas 77488

    Policy # 932452966

    $1,500.00
    1
    $1,500.00

    2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 1489 @ Highway 60 - Orchard, Texas

Subtotal $1,500.00
Total Due $1,500.00

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
November 18, 2020 @ 5:50 pm

Invoice updated by Geoffrey.