Bill To:


Farmers Insurance
PO Box 268993
Oklahoma City, OK 73126

Services Rendered To:


Jeffrey DwayneFarrow
P.O. Box 374
Weleetka, OK 74880
Policy # 512748583

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-49-015-2021-004 08/03/2021 08/05/2021 On Receipt Tiger Mountain Fire Dept.

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

    $350.00
    1.25
    $437.50
  2. 105 Utility Vehicle Response (Per Hour)

    $150.00
    1.25
    $187.50
  3. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  4. 306 Hose Per 50′ (Amt Used)

    $25.00
    2
    $50.00

  5. Additional Incident Info

    Incident Type: Vehicle Fire Response

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

    Ordinance Info: Tiger Mountain - McIntosh County Resolution 72021

Subtotal $690.00
Total Due $690.00


Updated
August 4, 2021 @ 12:41 pm

Invoice updated by Geoffrey.

Status Update
August 4, 2021 @ 12:41 pm

Status changed: Draft to Pending.

Viewed
October 24, 2022 @ 7:27 am

Invoice viewed by 64.124.8.45 for the first time.