The Law Offices of Seno and Associates
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Personal Injury & Auto Accidents


General client information for Seno and Associates
Please answer all questions to the best of your knowledge. Scroll down through all categories.

 Name
Address
 City, State, ZIP
Home Phone
Cell Phone
E-Mail
Married  
   Years   Spouse Name
Children  
   Age Child 1   Age Child 2   Age Child 3
Drivers License Number
Social Security Number
Date of Birth
Current Employer
Employer Address
Employer Phone
Years Working
Position / Salary
Highest Education  
Military Branch
Service Dates
Discharge Date
Referral
Physical / Mental Disabilities
Currently Under Medical Care
Alcohol Use    Frequency
Drug Use    Frequency

Personal Injury & Automobile Accidents - Details

Court Location
  Date   Room   Time
Any Pre-existing Conditions
Any Previous Accidents
Any drugs or alcohol taken prior to accident
Accident Date
Type of Accident
Injuries
Others Injured
Witness #1
Name, Address, Phone
Witness #2
Name, Address, Phone
Taken by Ambulance    Other?
Hospital / ER Name
Doctor #1
Name, Address, Phone
Doctor #2
Name, Address, Phone
Physical Therapy
Other Therapy
Accident Location
Police Report Number
Defendant
Name, Address, Phone
Injuries
Weather Conditions
Road Conditions
Direction of Your Car
Direction of Defendant Car
Damage to Your Car
Damage to Defendant Car
Traffic Signs / Signals
Your Vehicle Make   Model Year
Citations Issued
Your
Insurance Company
Defendant Insurance Company


This website is designed for general information only.
The information presented at this site should not be construed to be legal advice nor the formation of an attorney/client relationship.


 

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