| Claim ID: | 17757 |
| Submitted: | Dec-05-2018 |
| Requested Processing: | Photos required |
| Name: | Evasax |
| Email: | angle@probbox.com |
| Company: | |
| Phone: | 87356682721 |
| Their Claim No.: | |
| Insured: | |
| Policy No.: | |
| Date of Loss: | 1975-11-11 |
| Insured Address: | New York |
| Insured Telephone: | 84991272655 |
| Claimant Address: | New York |
| Claimant Telephone: | 83348888999 |
| Loss Location | USA |
| Local Authorities: | |
| Loss Description: | accutane |
| Handling Instructions: | accutane |