Bill To:


Highlander Specialty Insurance
B7 Tabonuco Street Suite 912
Guaynabo, PR 00968

Services Rendered To:


Jorge Gongora
12685 FM 359
Hempstead, TX 77445
POLICY# CH01-0000362-02

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-HW-405-23-122 09/29/2023 10/03/2023 On Receipt Hico VFD

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

    $400.00
    1
    $400.00
  2. 105 Utility Vehicle Response (Per Hour)

    $250.00
    1
    $250.00
  3. 418 Environmental Hazard Cleanup/Removal

    $250.00
    1
    $250.00
  4. 206 Latex Gloves (Pairs Used)

    $2.00
    10
    $20.00
  5. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  6. 309 Power Tool (# Used)

    $50.00
    1
    $50.00
  7. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1
    $100.00

  8. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 20975 US 281 N- Hamilton, TX

    Ordinance Info: Hico VFD Resolution

Subtotal $1,085.00
Total Due $1,085.00


Updated
October 3, 2023 @ 11:00 am

Invoice updated by Geoffrey.

Status Update
October 3, 2023 @ 11:00 am

Status changed: Draft to Pending.