Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Iwu Ahamefula
POLICY# 512 3058-H31-53 001

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BB-326-23-232-EE 12/07/2023 12/12/2023 On Receipt Rosharon VFD

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

    Patient

    Deaundre Holman
    2412 Crescent Dr
    Killeen, TX 76543
    POLICY# 6125727401

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 521- Rosharon, TX

    Ordinance Info: Rosharon Cost Recovery Resolution

Subtotal $1,500.00
Total Due $1,500.00


Updated
December 12, 2023 @ 11:33 am

Invoice updated by Geoffrey.