Bill To:


PROGRESSIVE INSURANCE – MEDICAL
6300 WILSON MILLS ROAD
MAYFIELD VILLAGE, OH 44143-2109

Services Rendered To:


Kevin Stokes
9682 Highway 8 North
Douglassville, Texas 75560
POLICY # 929007624
CLAIM# 22-7529266

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BY-205-22-0920-CMS 09/20/2022 01/05/2023 On Receipt Douglassville V.F.D.

Product
Price
Qty
Amount
  1. 218 Cervical Collar (# Used)

    $25.00
    1
    $25.00
  2. 803 Basic EMS Assistance (Response Fee)

    $250.00
    1
    $250.00
  3. 103 Rescue Response (Per Hour)

    $300.00
    1
    $300.00

  4. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: FM 995 - East of Highway 8 - Cass County, Texas

Subtotal $575.00
Total Due $575.00


Updated
January 5, 2023 @ 12:07 pm

Invoice updated by Geoffrey.