*First Name:
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| *Last Name: |
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| *Email: |
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| *Phone:
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| Fax: |
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| Cell: |
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| Other: |
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| State:
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| Date of Birth:
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(mm/dd/yyyy) |
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| Occupation:
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| Name of
Employer: |
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| Nature of
Disability: |
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| Last Date of
Employment: |
(mm/dd/yyyy) |
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What was the amount of your monthly salary? |
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| Are you receiving
Social Security Disability? If so, what is the monthly benefit?
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| What was or is
the amount of your monthly disability benefit? |
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| If receiving
Social Security, what is your benefit after offset? |
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| Are you receiving
Workers' Compensation Benefits? If so, what is the monthly benefit?
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| Type of
disability policy |
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| Was the insurance
premium paid by you or your company or both? |
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| Who was the
Insurance Carrier? |
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| When did you
first apply for disability? |
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(mm/dd/yyyy) |
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| Were you denied?
If so, when? |
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| Reason for the
denial? |
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| Did the carrier
send a denial letter? If so, what was the date of the letter?
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| Did the Insurance
Carrier inform you of an appeal deadline? If so, what was the date
of the deadline? |
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| Did you appeal?
If so, when? |
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| Was your appeal
denied? If so, when? |
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| Do you have a
copy of your policy?
Yes
No |
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| What percent of monthly salary did policy pay? |
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| Any dependent SSDI benefits? |
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| What date did WCAB benefit begin? |
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| What date did State Disability insurance
begin? |
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| Who was the
adjuster handling your claim? |
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| Who was your
primary doctor? |
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| Were you sent for
an Independent Medical Exam? If so, who was the doctor? When was this? |
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| Were there additional IMEs? If so, when. |
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| Did the carrier send a field representative to
interview you or your doctor? |
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| What are your doctors' specialties? |
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| What meds were you on at date of denial? |
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| What meds were you on at date of appeal denial? |
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| What meds are you on today? |
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| Are you behind in your mortgage, rent, car payments,
credit cards, etc.? |
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| Any criminal or tax problems we should know about? |
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| Comments: |
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