| Claim ID: | 16918 |
| Submitted: | Nov-22-2018 |
| Requested Processing: | Photos required |
| Name: | Janesax |
| Email: | mccrearycarpet@probbox.com |
| Company: | |
| Phone: | 83342898712 |
| Their Claim No.: | |
| Insured: | |
| Policy No.: | |
| Date of Loss: | 1978-11-12 |
| Insured Address: | San Jose |
| Insured Telephone: | 83267116222 |
| Claimant Address: | San Jose |
| Claimant Telephone: | 83633819925 |
| Loss Location | USA |
| Local Authorities: | |
| Loss Description: | amoxicillin clavulanate |
| Handling Instructions: | amoxicillin clavulanate |