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Practice Area*

How old are you?*

Do you expect to be out of work for at least a year due to your health?*

Have you been treated by a doctor, hospital, or clinic in the last year?*

Have you had a full time job within the past 5 years?*

Do you already receive Social Security benefits?*

Have you hired an advocate or attorney to help get benefits?*

What is your total debt?*

What is your total monthly income?*

Do You Own Real Estate?*

What is the estimated value of your assets?*

What is your role in this matter (do not complete form if you are a victim)*

When was the alleged crime committed?*

How will you pay legal fees if you hire a lawyer*

Total employees that work for the business*

The Employer is a*

Of What Country Are You a Citizen?*

How will you pay legal fees if you hire a lawyer*

Immigration Issue*

The person with the immigration matter is*

Status of the Claim*

When Did the Incident Occur?*

Primary Injury*

Prior Alcohol Related Offenses*

Type of Alcohol Test Performed*

Blood Alcohol Content Measured By Test*

Status of the Claim*

When Did the Incident Occur?*

Primary Injury*

Cause of Injury*

Do You Have Children*

Marital Status*

How will you pay legal fees if you hire a lawyer*

Was a Police Report Filed?*

When Did the Incident Occur?*

Primary Injury*

How will you pay legal fees if you hire a lawyer*

When did the charge occur?*

What type of charge?*

Your Relationship to Child(ren)*

With Whom Do the Children Currently Live?*

How will you pay legal fees if you hire a lawyer*

Who is the primary care-giver?*

Your Relationship to Child(ren)*

With Whom Do the Children Currently Live?*

How will you pay legal fees if you hire a lawyer*

Who is the primary care-giver?*

Do You Have Children*

Marital Status*

Do You Have Children*

Marital Status*

How will you pay legal fees if you hire a lawyer*

Family Law Issue*

Applicant's Occupation*

Applicant's Age (must be between 18 and 65)*

How did the applicant obtain the Long Term Disability policy?*

Has the applicant previously applied for Long Term Disability benefits?*

Has the applicant ever received Long Term Disability benefits for this claim?*

Applicant's monthly salary/pay when last at work*

Status of the Claim*

When Did the Incident Occur?*

Injuries From Medical Malpractice*

Type of Driver's License*

Traffic Violations*

Do You Have a Court Date*

Was a Police Report Filed?*

When Did the Incident Occur?*

Primary Injury*

What is your relationship to the applicant?*

Was the applicant hurt while on duty or is the condition related to military service?*

What service connected conditions does the applicant have? (select all that apply)*

Has the applicant applied for VA disability compensation?*

Case Description*

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