Bill To:


Loya Insurance Company
P.O. Box 972450
El Paso, TX 79997

Services Rendered To:


Levi O'Riaey
5102 FM 1806
Texas
Ph# 940-273-2652
Policy # 6673238225

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-WB-206-2020-1067-A 11/29/2020 10/25/2021 On Receipt Briar-Reno Fire Department

Product
Price
Qty
Amount
  1. 104 Tanker Response (Per Hour)

    $300.00
    1
    $300.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  3. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  4. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  5. 206 Latex Gloves (Pairs Used)

    $2.00
    5
    $10.00
  6. 326 Safety Fest (# Used)

    $2.50
    5
    $12.50
  7. 302 Hand Light (# Used)

    $5.00
    1
    $5.00

  8. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 730 North & Portwood Road - Azle, Texas

Subtotal $777.50
Total Due $777.50


Updated
October 24, 2021 @ 2:23 pm

Invoice updated by Geoffrey.

Status Update
October 24, 2021 @ 2:23 pm

Status changed: Draft to Pending.