Fire Recovery USA

Date: Run Number: Report Prepared By: Party Name: Party Address: Insurance Company & Agent Name: Agent Phone Number: Policy Number: Vehicle Make & Model: License Plate Number: Narrative (Please provide a brief description of duties performed): Department Name: Police Agency / Report #: Location of Incident: Resident: Y N

LLC

Motor Vehicle Accident Billing Report

Scene Procedures (Indicate all that apply): Traffic Control Hazardous Condition Hazardous Waste Removal Heavy Rescue Rope Rescue Airbags Helicopter Operations Property Damage MCI Flares and Cones Extrication Extrication with Tools C-Spine

Ambulance Transport Fire Suppression Vehicle Fire

FORM FAXED TO: 916- 290-0542 Date Faxed:

Contact: (888) 640-7222 219 Vernon Street Roseville, CA 95678