The Law Office of Terrence A. Low

Home=20 | Contact=20 Us | Do=20 I Have a Case?

244 Bridge Street, = Springfield,=20 MA 01103| Tel: (413)-785-1510; = Fax:=20 (413)-736-5640| terry@terryalow.com=20

Long-Term=20 Disability Questionnaire

=20 =20


Name:
Street Address (No P.O. Box, = please):
Telephone:
Home Fax:
Mobile / Cell Phone:
Email:
Date of Birth:
Soc. Security No.:
Marital Status:
Employer or Former = Employer:
Address of Employer:
Name of Insurance Company or = Benefit Plan=20 from which you are seeking benefits:

1.	What type of legal problem(s) do you=20 have? (Check all = that=20 apply)
	Lost pension or pension benefit too = low
	Lost health and welfare (medical or dental=20 insurance) benefit or health and welfare too = low
	Did not get a severance benefit
	Long-term disability insurance claim
	Workers' Compensation claim
	Social Security claim
2.	Please describe in the space below = what=20 happened and why you think you have a = claim.=20 (If you have difficulty = explaining=20 and you have a letter or other document you = think will=20 help us, please send a copy. Do = not send a=20 large number of documents.)
	=20
3.	(a) Have you filed an application for = benefits?=20 Yes=20 No=20
	(b) If so, when?
	(c) Did you receive a response to the = application?=20 Yes=20 No=20
	(d) If so, what was the date of the response? =
4.	Was your claim denied or terminated? Yes = No =
5.	Does the denial / termination letter state = that you=20 may appeal? Yes No
	Did you file an appeal? Yes No =
	If so, when? (Date)=20
	Did you get a response? Yes No =
	If so, when? (Date)=20
	If you did not get a response, when is the = appeal=20 due? (Date)
6.	(a) If this is a pension = claim, are=20 you seeking a lump sum amount? Yes = No =
	(b) If so, what is the amount? $
For Disability=20 Claims:
A.	Briefly describe your disability (list all = medical=20 conditions involved):
	=20
B.	(1) Are you currently receiving Social = Security=20 benefits? Yes=20 No=20
	(2) If not, have you applied before? Yes=20 =20 No
	(3) If you currently reveive or previously = received=20 Social Security benefits, what is/was the = monthly=20 amount? $ =
C.	Are you receiving Workers' Compensation = benefits?=20 Yes = No =
	If yes, what is the monthly amount? $
	If no, have you applied for Workers' = Compensation?=20
	What is the status of your Workers' = Compensation=20 claim? =
D.	What was your annual salary from your last = employer?=20 $
E.	If you receive or previously received = long-term=20 disability benefits, what is/was the gross = monthly=20 amount? $
F.	Briefly describe your work experience for the = past=20 15 years, beginning with the most = recent.
	=20
G.	Do you anticipate returning to your previous = job or=20 any other occupation in the near future? Yes=20 No
	If yes, when and to what position?
	If no, why?
H.	(a) Are you participating in any vocational=20 rehabilitation or educational program? = =20 Yes = =20 No
	(b) If yes, please list the name of the = program,=20 your proposed goal and the name and address of = your=20 counselor, if any. =20
PLEASE=20 READ CAREFULLY: I am submitting this = questionnaire and=20 attachments for review by The Law Office of = Terrence A.=20 Low. I understand the following: 1. That the submission of = information=20 is for review only and that there will be no = charge for=20 this review. 2. The Law Office of = Terrence A. Low=20 and I have not entered into an attorney-client=20 relationship and are not acting as my attorney = unless=20 and until a formal, written Retainer Agreement = has been=20 signed both by me and by a representative of The = Law=20 Office of Terrence A. Low. No decision has yet = been made=20 on whether The Law Office of Terrence A. Low = will take=20 my case and there is no guarantee that the firm = will=20 accept my case. 3. Further information may = be=20 requested in order for The Law Office of = Terrence A. Low=20 to reach a decision. 4. It takes time to review = the=20 material submitted and to make any reply or = decision.=20 Because no attorney-client relationship has yet = been=20 established, I will be responsible until I am = notified=20 otherwise to meet all necessary deadlines and = time=20 frames applicable to my claim; and I acknowledge = that I=20 have not received any representations or legal = opinions=20 with respect to any time frames or deadlines = that may be=20 applicable to my claim. I have read = and agree to=20 all of the above conditions. =20 = =20 =

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