Bill To:


STATE FARM MUTUAL INSURANCE
ONE STATE FARM PLAZA
BLOOMINGTON, IL 61710-0001

Services Rendered To:


Tonya Gonzales
1401 Scenic Dr
Longview, TX 75604
POLICY# 331 0079-D27-43J


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

    Patient

    Tonya Gonzales
    1401 Scenic Dr
    Longview, TX 75604
    POLICY# 331 0079-D27-43J

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: TX-42 & W Texaco Rd- Longview, TX

    Ordinance Info: City of White Oak Ordinance 2021-02

Subtotal $1,500.00
Total Due $1,500.00


Updated
July 3, 2023 @ 5:58 pm

Invoice updated by Geoffrey.

Viewed
July 5, 2023 @ 4:12 pm

Invoice viewed by Ken Kramer (kkramer) for the first time.