Bill To:


Germania Select Insurance Company
PO Box 645
Brenham, TX 77834

Services Rendered To:


Ira and Larry James
Policy# 4 304 003334009

Incident Table
Incident # Loss Date Invoice Date Terms Fire Dept
TX-BY205-2018-0413 04/13/2018 08/26/2019 On Receipt Douglassville Volunteer Fire Department

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

    $350.00
    1
    $350.00
  2. 103 Rescue Response (Per Hour)

    $300.00
    1
    $300.00
  3. 330 Backboard (# Used)

    $25.00
    1
    $25.00
  4. 216 Oxygen (# Used)

    $25.00
    1
    $25.00
  5. 409 Manpower (Per Hour)

    $20.00
    3
    $60.00

  6. Additional Incident Info

    Incident Type: MVA Response

    Incident Location: SH77W East of Park

Subtotal $760.00
Total Due $760.00
Updated
August 24, 2019 @ 8:11 pm

Invoice updated by Karen Smith.

Status Update
August 24, 2019 @ 8:11 pm

Status changed: Draft to Pending.

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