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*First Name:
*Last Name:
*Email:
Phone:
State:
Date of Birth: (mm/dd/yyyy)
Occupation:
Name of Employer:
Nature of Disability:
Last Date of Employment: (mm/dd/yyyy)
What was the amount of your monthly salary?
Are you receiving Social Security Disability? If so, what is the monthly benefit?
What was or is the amount of your monthly disability benefit?
If receiving Social Security, what is your benefit after offset?
Are you receiving Workers' Compensation Benefits? If so, what is the monthly benefit?
Was the insurance premium paid by you or your company or both?
Who was the Insurance Carrier?
When did you first apply for disability? (mm/dd/yyyy)
Were you denied? If so, when?
Type of disability policy:
Reason for the denial?
Did the carrier send a denial letter? If so, what was the date of the letter?
Did the Insurance Carrier inform you of an appeal deadline? If so, what was the date of the deadline?
Did you appeal? If so, when?
Type of disability policy:
Was your appeal denied? If so, when?
Do you have a copy of your policy?
Who was the adjuster handling your claim?
Who was your primary doctor?
Were you sent for an Independent Medical Exam? If so, who was the doctor?
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