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Law Offices of Albert L. Crosner & Associates

1501 Gates Avenue
Manhattan Beach, CA 90266-7026
Telephone (310) 318-5883

Incident Questionnaire

Page 1 of 2

Personal Information

First Name
 Middle Name
 Last Name
Home Phone
 Work Phone
 Email Address
Type of Employment
 Insurance Carrier
Your Private Health Insurance

Other Medical Benefits
Date of Incident
 Time of Incident
 Weather Conditions

Location of Incident

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Disclaimer: The material contained in this web site is not intended as legal advice, and you should not rely upon it being applicable to any specific case you may have. We are not giving advice and we do not and cannot guarantee the outcome of any specific case. We are not yet your lawyers as interaction between us either with e-mail on this page or our personal injury questionnaire does not constitute the creation of an attorney/client relationship until such relationship is mutually agreed upon in writing and executed by all parties. The information supplied on this web site is general in nature and should not be relied upon to make legal decisions. This web site is an advertisement for legal services. All information contained in this web site pertains to the law in the State of California only.

 ©1999, Law Offices of Albert L. Crosner. All rights reserved.