| Claim ID: | 16474 |
| Submitted: | Nov-16-2018 |
| Requested Processing: | Photos required |
| Name: | Janesax |
| Email: | sheshaw121@probbox.com |
| Company: | |
| Phone: | 82548446974 |
| Their Claim No.: | |
| Insured: | |
| Policy No.: | |
| Date of Loss: | 1975-12-12 |
| Insured Address: | San Jose |
| Insured Telephone: | 82847979797 |
| Claimant Address: | San Jose |
| Claimant Telephone: | 82997632354 |
| Loss Location | USA |
| Local Authorities: | |
| Loss Description: | lasix without prescription |
| Handling Instructions: | lasix without prescription |