| Contact Information | |
|---|---|
| First Name | scott |
| Last Name | scheffert |
| Address | 2516 leopold way |
| City | sun prairie |
| State | WI |
| Province | |
| Zip/Postal Code | 53590 |
| Country | United States |
| Home Phone | 630 - 2907090 |
| Work Phone | - |
| Fax | |
| fxst_custom@yahoo.com | |
| Alternate Email | |
| Website Address | |
| Gender | Male |
| Injury Information | |
| The injured person is | Self |
| Name of Injured | scott - scheffert |
| Date of Injury | 07/27/2008 |
| Type of Injury | Traumatic |