Bill To:


Old American County Mutual
P.O. Box 793747
Dallas, TX 75379-3747

Services Rendered To:


Deirdre Rhodes
1557 Nash Road
Lufkin, Texas 75901
Policy # TEJ01721816-02

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-AC-309-2021-12 03/03/2021 03/05/2021 On Receipt Zavalla Fire Department

Product
Price
Qty
Amount
  1. 103 Rescue Response (Per Hour)

    $300.00
    1.25
    $375.00
  2. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1.25
    $187.50
  3. 309 Power Tool (# Used)

    $50.00
    1
    $50.00
  4. 310 Hydraulic Tool (# Used)

    $200.00
    1
    $200.00
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.25
    $125.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 1270 at Saron Road - Zavalla, Texas

Subtotal $1,187.50
Total Due $1,187.50


Updated
March 4, 2021 @ 3:07 pm

Invoice updated by Geoffrey.

Status Update
March 4, 2021 @ 3:07 pm

Status changed: Draft to Pending.

Viewed
October 24, 2022 @ 2:06 pm

Invoice viewed by 64.124.8.26 for the first time.