Full name:

Email Address:

Phone:

City:

State:

Type of Policy: Employer-sponsored  Individual Policy 

Name of Insurance Company: (if known)

Have you applied yet? Yes  No 

If yes, has your claim been denied? Yes  No 

If yes, what was the reason for the denial? (if one was provided)

If your claim was denied, have you filed an appeal? Yes  No 

Please identify, explain or describe your disabling condition.

Are there are time deadlines for you to appeal or contest any claims denial? If so, please explain.

Have you had any prior legal representation in connection with your disability claim? Yes  No 

Approximate date last worked (month / day / year)

Have you filed a claim for Social Security Disability Benefits? Yes  No 

If you have filed, what is the status of your claim?  Awaiting determination
 Denied
 Reconsideration stage
 Awaiting hearing

Any other information you want to provide us about your matter?

How did you find out about us?