Long-Term Disability Questionnaire

Thank you for filling out this questionnaire. In order to determine if we can be of service to you, it will be useful for you to answer a few specific questions. At the end of the questionnaire, hit the SUBMIT button.

If you prefer you may fill the form, print it and fax to us at (206) 374-7377
Or, you may print the form, scan it, and email it to: klf@krafchick.com
Most find filling it out and hitting the SUBMIT button to be easiest.

Click here for the printable version.

Treating doctor(s) supporting your claim for disability?

Have you received your short-term disability benefits?
If yes, paid by:


Have you received your long-term disability benefits?
If yes, paid by:


Do you know if your plan is covered by ERISA (Employee Retirement Income Security Act)?

Status of your disability claim?


is trying to terminate the benefits


Do you have a copy of a letter either denying or terminating your disability benefits that you can scan
and email or fax to us? Our fax: 206-374-7377

Did the disability plan or insurer deny your benefits for any of the following reasons: (check all that apply)

      and has paid you for 24 months for disability for your own occupation

Have you appealed your denial or termination of your long or short term disability benefits?
Date of your appeal:       
Appeal granted?
         Date of appeal decision:       

Social security disability benefits
      Have you applied?
      Were benefits granted?
      Amount of monthly benefit

Workers compensation claim?
      Have you applied?
      Were benefits granted?
      Amount of monthly benefit or lump sum

Anything else you would like us to know about you or your disability claim:

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Case results will vary, based on the facts of each individual case. Krafchick Law Firm does not offer a guarantee of positive case results. All potential clients are urged to make an independent evaluation of any personal injury lawyer under consideration.

We urge potential clients to review our website, our experience and credentials.