| Contact Information | |
|---|---|
| First Name | Rich |
| Last Name | Smith |
| Address | 3224 Osborne blvd. |
| City | Racine |
| State | WI |
| Province | |
| Zip/Postal Code | 53405 |
| Country | United States |
| Home Phone | 262 - 632-9693 |
| Work Phone | 262 - 260-2707 |
| Fax | |
| smith@rootcom.net | |
| Alternate Email | rasmith@scj.com |
| Website Address | |
| Gender | Male |
| Injury Information | |
| The injured person is | Self |
| Name of Injured | Rich - Smith |
| Date of Injury | 08-02-05 |
| Type of Injury | Traumatic |