Bill To:


Home State County Mutual Insurance
P.O. Box 8036
Waco, TX 76714-8036

Services Rendered To:


Thomas Xavier Rashad
7414 Blue Jay Dr
Texas City, TX 77591
POLICY# 00200103

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BB-326-23-213-A 11/01/2023 12/05/2023 On Receipt Rosharon VFD

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

    $500.00
    1.25
    $625.00
  2. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1.25
    $312.50
  3. 103 Rescue Response (Per Hour)

    $400.00
    1.25
    $500.00
  4. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.25
    $125.00
  5. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 655- Rosharon, TX

    Ordinance Info: Rosharon Cost Recovery Resolution

Subtotal $2,062.50
Total Due $2,062.50


Updated
December 5, 2023 @ 3:05 pm

Invoice updated by Geoffrey.

Status Update
December 5, 2023 @ 3:05 pm

Status changed: Draft to Pending.