Bill To:


Progressive Insurance
6300 Wilson Mills Rd.
Mayfield, OH 44143

Services Rendered To:


Jolinda Bell
3000 North Hiwassee
Choctaw, OK 73020
Policy # 928727636

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
OK-49-007-2020-31901 03/19/2020 12/26/2020 On Receipt F.A.I.C. V.F.D.

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

    $500.00
    1.5
    $750.00
  2. 206 Latex Gloves (Pairs Used)

    $2.00
    1
    $2.00
  3. 407 Patient Care / Evaluation (Per Patient)

    $50.00
    1
    $50.00

  4. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: I-40 West Bound @ MM 255 - Choctaw, OK

Subtotal $802.00
Total Due $802.00
Updated
December 26, 2020 @ 6:42 pm

Invoice updated by Geoffrey.

Status Update
December 26, 2020 @ 6:42 pm

Status changed: Draft to Pending.

Updated
December 26, 2020 @ 6:45 pm

Invoice updated by Geoffrey.

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