Name:
Date of Birth:
Telephone:
Address:
Email:
Best Time for an attorney to contact you:
1. When did you last work?
Month
Year
2. Did you ever receive Social Security disability income (if the answer is NO, go to Question 6)?


3. If so, when did it begin?
Month
Year
4. If it has ended, when did it end?
Month
Year
5. How much do (did) you get each month in social security disability income?
6. When did you submit your claim for disability benefits?
Month
Year
7. Did you ever receive any disability benefits(If the answer is NO, go to question 11.)?


8. When did the benefits begin?
Month
Year
9. When did the benefits end?
Month
Year
10. Why did the insurance company say it was stopping payments?
11. If you never received any disability benefits, when was your claim denied?
Month
Year
12. Did you ask them to reconsider or did you appeal the denial?


13. If yes, did they uphold the denial on appeal or reconsideration?


14. When did they decide the appeal?
Month
Year
15. Did you settle your claim with your insurance company


16. Did you file a lawsuit against your insurance company?


17. What type of work did you do?
18. Who was your employer?
19. What was your annual income when you began to get sick?
20. What is the nature of your illness or disability
21. How did you hear about us?
22. Is there anything else you would like us to know?

 

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* Please specify the subject(s) of your claim:

Disability
Life
Health
Long Term Care
Other Insurance

-- If other, please describe.

* Has the insurance company already denied your claim?

Yes
No

* What is the name of your insurance company?

* Briefly describe the nature of your claim:


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