ERISA / Long Term Disability Questionnaire

Please complete the following form in advance of your appointment. Thank you.

Name*

Date of Intake*

Address*


Email*

Phone*

Employer*

Position*

Last Date Worked*

Annual Salary*

If you have received benefits, what is the amount of:

  

LTD Amount Before Offset

SSD Amount

Is There an Offset?

Have you filed a claim for disability with any agency or insurance company?

If so, with whom and when?

Have you received a decision?

If so, what is the date of that decision?

Have you appealed?

Do you have any current deadlines or appeal?