Bill To:


Loya Insurance Company
P.O. Box 972450
El Paso, TX 79997

Services Rendered To:


Stormi Wilshire
21115 FM 850
Tyler, Texas 75790
Driver: Jonathan Willis
Policy # 65-383136399

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-HP-309-2021-73-E 05/10/2021 06/03/2021 On Receipt White Oak Fire Department

Product
Price
Qty
Amount
  1. 406 Medical Extrication – Lvl 2

    Patient:

    Stormi Wilshire
    21115 FM 850
    Tyler, Texas 75790

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: Highway 42 & Highway 80 - White Oak, Texas

    Ordinance Info: Ordinance 2021-02 Section 30-6

Subtotal $1,500.00
Total Due $1,500.00


Updated
June 3, 2021 @ 1:15 pm

Invoice updated by Geoffrey.

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