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content-disposition: form-data; name="_token"

nFLzXcfviha0leLiZO2B26yI8DxVk4ZLcsLv6eZO
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content-disposition: form-data; name="customer_id"

297440e2-38cd-475e-bdf4-60fea6458511
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content-disposition: form-data; name="date_of_injury"

12/17/2008
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content-disposition: form-data; name="category_id"

10000
------WebKitFormBoundaryIu7qMsTB91Bgs5nN--
