Bill To:


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

Services Rendered To:


Jackie Wright
32081 US Hwy 31
Calera, AL 35040
POLICY# 0134216843

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
AL-01-403-23-1121 10/11/2023 10/19/2023 On Receipt Jemison Fire Department

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

    $500.00
    1
    $500.00
  2. 303 SCBA Breathing Apparatus (# Used)

    $50.00
    2
    $100.00
  3. 304 SCBA Cylinder (# Used)

    $25.00
    2
    $50.00
  4. 306 Hose Per 50′ (Amt Used)

    $25.00
    4
    $100.00
  5. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00

  6. Additional Incident Info

    Incident Type: Vehicle Fire Response

    Incident Location: 2200 CR 627- Thorsby, AL

Subtotal $1,000.00
Total Due $1,000.00


Updated
October 19, 2023 @ 10:05 am

Invoice updated by Geoffrey.

Status Update
October 19, 2023 @ 10:05 am

Status changed: Draft to Pending.