Dr Claim Insurance Company Type Amount Meek teach led Men 111E pontos of dateniat %eat, pa:nall AMOUNT ENCLOSED AMOUNT DUE 3375.00 Remit by Account Numbcr 06/18115 Visa MC Acct# Exp.Date Security Code Signature Amount -••••••• awn. ••••••.• swot Staten Island, NY 10314 New Yor ew o , 10019