* Last Name:
* Phone Number
Phone Number (eve):
What is this person's relationship
Affected person's date
Have you or they been denied
long-term disability benefits or had benefits terminated?
Were you denied by Social
Security or a private insurance carrier?
If private insurance carrier,
what was the name of your carrier?
What was the estimated
date of the denial?
What reason were
you given for the denial?
Have you signed up for
any type of reassessment program?
Have you received any
type of lump sum settlement?
was your monthly benefit payment excluding
State disability, Worker's Compensation and Social Security?
What was your
monthly benefit payment including State
disability, Worker's Compensation and Social Security?
Did you have a group or individual
Have you returned to work since
you originally filed the claim?
Do you currently have an attorney
assisting you in this matter?