Bill To:


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

Services Rendered To:


Nicholas Vancura
4624 Faulkner Dr
Plano, TX 75024
POLICY# 5344709H1043C001

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-XV-414-23-1755 10/29/2023 10/30/2023 On Receipt Sam Bass Fire Department

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

    $500.00
    1
    $500.00
  2. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1
    $250.00
  3. 106 Battalion/Chief Vehicle Response (Per Hour)

    $200.00
    1
    $200.00
  4. 301 Hand Tool (# Used)

    $15.00
    2
    $30.00
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  6. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 2936 N SH 45W- Round Rock, TX

    Ordinance Info: Sam Bass Fire Dept. Resolution

Subtotal $1,330.00
Total Due $1,330.00


Updated
October 30, 2023 @ 10:20 am

Invoice updated by Geoffrey.

Status Update
October 30, 2023 @ 10:20 am

Status changed: Draft to Pending.