Bill To:


Assurance America Insurance
P.O. Box 725009
Atlanta, GA 31139-0009

Services Rendered To:


Marvin Carrasco
1312 Knox Street
Griffin, GA 30223
Policy # PGA1923466

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-49-015-21-1101 11/01/2021 12/08/2021 On Receipt Tiger Mountain Fire Dept.

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

    $500.00
    1.75
    $875.00
  2. 102 Engine Response (Per Hour)

    $500.00
    1.75
    $875.00
  3. 105 Utility Vehicle Response (Per Hour)

    $500.00
    1.75
    $875.00
  4. 401 Debris Cleanup/Removal (# Used)

    $250.00
    1
    $250.00
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.75
    $175.00
  6. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  7. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: I-40 Westbound @ MM 247 - Henryetta, OK

    Ordinance Info: Tiger Mountain - McIntosh County Resolution 72021

Subtotal $3,300.00
Total Due $3,300.00


Updated
December 8, 2021 @ 4:51 pm

Invoice updated by Geoffrey.

Status Update
December 8, 2021 @ 4:51 pm

Status changed: Draft to Pending.

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