Bill To:


ALLSTATE PIP / MED PAY
PO BOX 2874
CLINTON, IA 52733-2874

Services Rendered To:


Sargent Marine
100 Clement Road
Sargent, TX 77414
Driver: Jeremy Johnson
Policy # 838-984-463


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

    Patient:

    Jeremy Johnson
    6918 Perry Court
    Houston, TX 77021
    Policy # 838-984-463

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 8214 FM 457 - Sargent, Texas

Subtotal $1,500.00
Total Due $1,500.00


Updated
December 22, 2021 @ 6:09 pm

Invoice updated by Geoffrey.

Updated
December 22, 2021 @ 6:10 pm

Invoice updated by Geoffrey.

Viewed
October 24, 2022 @ 6:51 am

Invoice viewed by 64.124.8.42 for the first time.