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C LAPP O CHS TRIAL LAWYERS 323 South David Street Casper WY 82601 Phone 307. 234. 3239 www. clappochs. Com Wyoming California Colorado CONFIDENTIAL PRODUCT LIABILITY QUESTIONNAIRE TODAY S DATE NAME ADDRESS HOME PHONE WORK PHONE EMPLOYER/FORMER EMPLOYER NAME DATE OF BIRTH SOCIAL SECURITY SPOUSE S NAME WORK PHONE EMPLOYER NAME Page 1 of 6 LIABILITY Dates of PRODUCT USE Start Date End Date Which physician s ordered / prescribed / etc for you List all names addresses and/or phone numbers of...
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