This form below is optional, but the more detail you are able to provide, the faster we will be able to respond to your specific inquiry. Thanks!

1. What type of legal problem(s) do you have? (Check all that apply)
Long-term Disability Insurance Claim
Social Security Claim

2. Please describe in the space below what happened and why you think you have a claim. If you have difficulty explaining and you have a letter or other document you think will help us, please send a copy. Please do not send a large number of documents.

3. (a) Have you filed an application for benefits?
Yes No

(b) If so, when?

(c) Did you receive a response to the application?
Yes No

(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 the you may appeal?
Yes No

Did you file an appeal?
Yes No

If so, when? (Date)

Did you get a response?
Yes No

If so, when? (Date)

If you did not get a response, when is the appeal due? (Date)

A. Briefly describe your disability (list all medical conditions involved):

B.(1) Are you currently receiving Social Security benefits?
Yes No

(2) If not, have you applied before?
Yes No

(3) If you currently receive or previously received Social Security benefits, what is/was the monthly amount?

C. Are you receiving benefits?
Yes No

If yes, what is the monthly amount?

If no, have you applied for benefits?
Yes No

What is the status of your claim?

D. What was your annual salary from your last employer?

E. If you receive or previously received long-term disability benefits, what is/was the gross monthly amount?

F. Briefly describe your work experience for the past 15 years, beginning with the most recent.

G. Do you anticipate returning to your previous job or any other occupation in the near future?
Yes No

If yes, when and to what position?

If no, why?

H. (a) Are you participating in any vocational rehabilitation or educational program?
Yes No

(b) If yes, please list the name of the program, your proposed goal and the name and address of your counselor, if any.

PLEASE READ CAREFULLY:

I am submitting this questionnaire and attachments for review by Sims, Stakenborg & Henry. I understand the following:

1. That the submission of information is for review only and that there will be no charge for this review.
2. Sims, Stakenborg & Henry and I have not entered into an attorney-client relationship and are not acting as my attorney unless and until a formal, written Retainer Agreement has been signed both by me and by a representative of Sims, Stakenborg & Henry. No decision has yet been made on whether Sims, Stakenborg & Henry will take my case and there is no guarantee that the firm will accept my case.
3. Further information may be requested in order for Sims, Stakenborg & Henry to reach a decision.
4. It takes time to review the material submitted and to make any reply or decision. Because no attorney-client relationship has yet been established, I will be responsible until I am notified otherwise to meet all necessary deadlines and time frames applicable to my claim; and I acknowledge that I have not received any representations or legal opinions with respect to any time frames or deadlines that may be applicable to my claim.

I have read and agree to all of the above conditions.