Bill To:


STATE FARM INSURANCE
PO BOX 52250
PHOENIX, AZ 85072-2250

Services Rendered To:


Sally Thompson McCommon
17088 Faircrest Dr
Whitney, TX 76692
POLICY# 157 4084-F10-43J 001

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-KP-401-22-141-EE 08/17/2022 03/28/2023 On Receipt Peoria V.F.D.

Product
Price
Qty
Amount
  1. 405 Medical Extrication – Lvl 1

    Patient

    Sally Thompson McCommon
    17088 Faircrest Dr
    Whitney, TX 76692
    POLICY# 157 4084-F10-43J 001

    $500.00
    1
    $500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: State Hwy 22 & Hcr 2421 E- Hillsboro, TX

    Ordinance Info: Recovery of Service Costs for Peoria VFD

Subtotal $500.00
Total Due $500.00


Updated
March 28, 2023 @ 3:03 pm

Invoice updated by Geoffrey.

Viewed
March 30, 2024 @ 12:54 am

Invoice viewed by 66.249.72.4 for the first time.