Bill To:


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

Services Rendered To:


Johny McLellan
4333 Edinburg Way
Del City, OK 73115
POLICY# 3623676701

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-41-016-23-70 05/07/2023 05/08/2023 On Receipt Jacktown Fire Protection District

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

    $300.00
    1
    $300.00
  2. 105 Utility Vehicle Response (Per Hour)

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

    $150.00
    1
    $150.00
  4. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  5. 106 Battalion/Chief Vehicle Response (Per Hour)

    $150.00
    1
    $150.00
  6. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  7. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00
  8. 206 Latex Gloves (Pairs Used)

    $2.00
    4
    $8.00
  9. 201 Oil Absorbent Material (# Used)

    $35.00
    1
    $35.00
  10. 419 Environmental Spill

    $250.00
    1
    $250.00
  11. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  12. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 100600 Hwy 177- Meeker, OK

Subtotal $1,718.00
Total Due $1,718.00


Updated
May 8, 2023 @ 2:37 pm

Invoice updated by Geoffrey.

Status Update
May 8, 2023 @ 2:37 pm

Status changed: Draft to Pending.