Long Term Disability
New Client Information
Today's Date
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First Name
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Last Name
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Street Address
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Street Address Line 2
City of Street Address
State of Street Address
Zip Code of Street Address
Best Number to Contact
Email Address
Referred By
Date Last Worked
Disability
Occupation/Job Description
Date of Birth
Social Security Number
Salary/LTD Benefit Amount
Applied/Approved for SSD?
Amount of SSD?
Insurance Company
Name of Employer/Insurance Company
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Street Address of Adverse Party
Address of Adverse Party Line 2
City of Address of Adverse Party
State of Address of Adverse Party
Zip Code of Address of Adverse Party
Date of First Denial Letter
Date of Second/Final Denial Letter
Have you requested the Claims File?
List of Doctors and Addresses for past year
Hospitalizations/Surgeries
Medications
Additional Information
Initial Consultation
The law firm of Morgan & Paul, PLLC will provide an initial consultation and no attorney fees will be charged. By agreeing to the submission of this form, you agree that an attorney-client relationship is not created until a retainer agreement is signed and executed by both the client and the law firm. By selecting the “Yes, I Accept” button at the end of this Agreement, you agree to contract electronically and acknowledge that you have read and agree to be bound by the terms of this Agreement.
Yes, I Accept
No, I Do Not Accept.