Bill To:


GREAT WEST CASUALTY
1100 WEST 29th STREET
SOUTH SOUIX CITY, NE 68776-3130

Services Rendered To:


Nicklin Trucking
278 Omega Dr
Lawrenceville, GA 30044
POLICY# GRT05338A


Product
Price
Qty
Amount
  1. 406 Medical Extrication – Lvl 2

    Patient

    Christopher Maddox
    743 AL Hwy 191
    Jemison, AL 35085

    $1,500.00
    1
    $1,500.00

  2. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: 214 I-65 NB- Clanton, AL

Subtotal $1,500.00
Total Due $1,500.00


Updated
March 14, 2024 @ 3:53 pm

Invoice updated by Geoffrey.