Bill To:


Farmer's Insurance
PO Box 0991
Carol Stream, IL 60132-0991

Services Rendered To:


Kyle Gragg
276 Wayland Rd
Lufkin, TX 75904
POLICY# 510011423

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-AC-501-23-130 10/10/2023 10/31/2023 On Receipt Moffett VFD

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

    $500.00
    2.25
    $1,125.00
  2. 103 Rescue Response (Per Hour)

    $400.00
    2.25
    $900.00
  3. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  4. 206 Latex Gloves (Pairs Used)

    $2.00
    5
    $10.00
  5. 404 Scene Lighting (Per Hour)

    $75.00
    2.25
    $168.75
  6. 403 Traffic Control / Road Closure (Per Hour)

    $100.00
    2.25
    $225.00
  7. 215 Trauma Kit (# Used)

    $25.00
    1
    $25.00
  8. 327 Windshield Kit (# Used)

    $25.00
    1
    $25.00
  9. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  10. 408 Air Medical Landing Zone (Used)

    $250.00
    1
    $250.00
  11. 330 Backboard (# Used)

    $25.00
    1
    $25.00

  12. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 10254 State Hwy 103 E- Lufkin, TX

Subtotal $3,028.75
Total Due $3,028.75


Updated
October 31, 2023 @ 10:22 am

Invoice updated by Geoffrey.

Status Update
October 31, 2023 @ 10:22 am

Status changed: Draft to Pending.