Bill To:


Suzanne Klaviter
13232 Alyssum Drive
Fort Worth, TX 76244

Services Rendered To:


Suzanne Klaviter
13232 Alyssum Drive
Fort Worth, TX 76244
Driver: Spencer Klaviter
POLICY # 15TX5678621


*** THIS HAS BEEN SUBMITTED TO YOUR INSURANCE COMPANY AND DENIED. THIS IS NOW YOUR RESPONSIBILITY. ***

Product
Price
Qty
Amount
  1. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  2. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  3. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  4. 206 Latex Gloves (Pairs Used)

    $2.00
    10
    $20.00
  5. 301 Hand Tool (# Used)

    $15.00
    2
    $30.00
  6. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00
  7. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  8. 207 Wetting Agent (Amt Used)

    $25.00
    4
    $100.00
  9. 324 Traffic Cone (# Used)

    $5.00
    10
    $50.00
  10. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  11. 404 Scene Lighting (Per Hour)

    $75.00
    1
    $75.00

  12. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: State Highway 22 and FM 1947 - Hillsboro, Texas

    Ordinance Info: Recovery of Service Costs for Peoria VFD

Subtotal $1,075.00
Total Due $1,075.00


Updated
February 4, 2022 @ 3:05 pm

Invoice updated by Geoffrey.

Status Update
February 4, 2022 @ 3:05 pm

Status changed: Draft to Pending.

Updated
February 4, 2022 @ 3:05 pm

Invoice updated by Geoffrey.

Updated
September 23, 2022 @ 3:56 pm

Invoice updated by Geoffrey.

Updated
September 23, 2022 @ 3:56 pm

Invoice updated by Geoffrey.