Bill To:


Wesley Juarez
208 Palm Ln
Lake Jackson, TX 77566

Services Rendered To:


Wesley Juarez
208 Palm Ln
Lake Jackson, TX
POLICY# 4563605866

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BB-326-23-202-B 10/17/2023 10/23/2023 On Receipt Rosharon VFD

*** THIS HAS BEEN SUBMITTED TO YOUR INSURANCE COMPANY AND DENIED. THIS IS NOW YOUR RESPONSIBILITY. ***

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

    $400.00
    2
    $800.00
  2. 104 Tanker Response (Per Hour)

    $400.00
    2
    $800.00
  3. 105 Utility Vehicle Response (Per Hour)

    $250.00
    2
    $500.00
  4. 206 Latex Gloves (Pairs Used)

    $2.00
    6
    $12.00
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    2
    $200.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  7. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  8. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 1462 on Hwy- Rosharon, TX

    Ordinance Info: Rosharon Cost Recovery Resolution

Subtotal $2,812.00
Total Due $2,812.00


Updated
October 23, 2023 @ 11:00 am

Invoice updated by Geoffrey.

Updated
February 15, 2024 @ 11:29 am

Invoice updated by Geoffrey.

Viewed
July 21, 2024 @ 9:29 pm

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