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October 20, 2016

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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*

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
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