ERISA / Long Term Disability Questionnaire

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Date of Intake(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer(Required)

Position(Required)

Last Date Worked

Annual Salary

LTD Amount Before Offset

SSD Amount

Is there an offset?

Yes

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

Yes

If Yes – with whom and when?

Have you received a decision?

Yes

If Yes – what is the date of that decision?

Have you appealed?

Yes

Do you have any current deadlines or appeal?(Required)