Bill To:


STATE FARM MUTUAL INSURANCE
ONE STATE FARM PLAZA
BLOOMINGTON, IL 61710-0001

Services Rendered To:


Policy# 365 6176-K05-43A 001
Owner: Belinda Morrison
Driver: Brandon Morrison
2279 CR 127
Whitesboro, TX 76273

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-CW-201-23-476629 01/12/2023 01/17/2023 On Receipt Callisburg VFD

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

    $350.00
    1.75
    $612.50
  2. 310 Hydraulic Tool (# Used)

    $200.00
    1
    $200.00
  3. 301 Hand Tool (# Used)

    $15.00
    1
    $15.00
  4. 404 Scene Lighting (Per Hour)

    $75.00
    1.75
    $131.25
  5. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    1.75
    $175.00
  6. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  7. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00

  8. Additional Incident Info

    Incident Type: MVA w/Entrapment Response

    Incident Location: FM 371, North of CR 134, Gainesville, TX 76240

Subtotal $1,408.75
Total Due $1,408.75


Updated
January 17, 2023 @ 2:07 pm

Invoice updated by Karen Smith.

Status Update
January 17, 2023 @ 2:07 pm

Status changed: Draft to Pending.