Potential Client Questionnaire
For all types of claim
Salutation:(Dr., Mr. or Ms.)
Please enter a valid phone number.
Street Address Line 2
District of Columbia
Date of Birth
Age (will calculate after DOB entered)
What type of claim do you need help with?
If short term disability or SSDI, do you also have long term disability insurance coverage?
What is the status of your claim?
Denied, have not appealed
Denied, appeal filed and pending
Denied, final denial received
Not applied yet
What is the date of the most recent denial?
Information about the disability
For LTD, STD, SSDI, and disability pension
When did you become disabled?
When did you last work?
What was your job before disability
What is your disability?
Do you have a doctor(s) who says you are disabled?
Name(s) and Type(s) of doctors who support disability?
Does your doctor say you will never be able to go back to work?
[optional] Additional notes about doctor's disability opinion:
Do you think you will be able to go back to work?
If you think you might return to work, when and how?
Information about Life Insurance Claim
When did the person pass away
When did they last work?
What caused them to pass away?
Health Insurance Claim Information
What is your benefit that is being denied (what procedure, treatment, or medication, etc)?
Who is your doctor that is prescribing this?
How much is the cost of the procedure/treatment/medication?
Have you paid any of the bill(s)?
How much have you paid toward the medical bills/procedure?
Are you eligible for Medicare or Medicaid?
Subrogation Claim Information
Nature of underlying claim
What is the date of the original accident or injury?
Are you represented by an attorney for the underlying claim
What is the name of your attorney?
What is the status of the underlying claim?
What city/state did the incident occur?
Is the case in court?
Has there been a settlement offer in the underlining case?
What was the offered amount?
Name of the health insurance company:
How much is the health insurance company trying to get paid back?
How much money has already been paid back to the health insurance company?
Has the health insurance offered to take less than the full amount?
How much have they offered to take?
Can they fax or mail in the letter from the health insurance company?
Pension or Retirement Claim Information
Who is pension from?
What is the name of Union?
What is the name and address of the employer?
What is the benefit being denied?
How much is your pension/retirement benefit?
Information about the insurance policy
For LTD, STD, health, and life insurance
What is the name of the insurance company that you have your insurance policy through?
Did you get your insurance policy through work or on your own?
What is the name of the employer and city/town where you worked?
What state did you live in when you bought it?
Long Term Care Claim Information
When did they begin to need long-term care treatment?
What is your health condition that requires long-term care?
What doctor says they’re disabled and need long-term care?
Is the long term care likely permanent or temporary?
If temporary, how long do they expect to need it?
Do you have Medicare/Medicaid or some other insurance that might pay some part of your long-term care?
If yes, what is it?
(Partial) LTD, STD, life insurance, Health and disability pension
Have you received benefits already?
If yes, since when?
Disability: What did they say was the reason for your denial?
Not disabled: Say I can do my own job
Not disabled: Say I can transfer to another job
Life Insurance: What did they say was the reason for your denial?
Not eligible for coverage
Exclusion eliminates coverage
Health Insurance: What did they say was the reason for your denial?
Out of network
What is the reason for the benefits being denied or reduced?
Pension or long term care
Why is that reason wrong?
Life Insurance, Pre-Existing Condition
What is the deadline to appeal?
Did you file the appeal?
If you filed the appeal, what date did you file it?
(Partial) LTD, STD, Life Insurance, Disability Pension
Do you know how much you would draw per month if approved?
If yes, how much?
Is this before or after SS offset
"Before the offset" means that they are telling us the gross benefit and we would expect that benefit to be reduced by SSDI when it is awarded. "After the offset" is the net benefit and we would not apply an offset to it.
Disability: Do you know what percentage of your wages your disability benefit is?
Life Insurance: Do you know how much the life insurance would be?
Life Insurance: How much would the life insurance be?
Life Insurance: Is the benefit amount based on the amount of the deceased person's pay or salary?
Life Insurance: Were the deceased person's wages paid by salary or hourly?
Disability: Before you became disabled, were you paid salary, hourly, or commission?
If paid salary/commission, what was the yearly income
If paid by the hour, what was the hourly wage
If hourly wage, how many hours per week? (on average)
Social security claim
For LTD, SSD
Have you filed for Social Security?
If you have filed for SSDI, what is the status and the date of the most recent denial?
Have you been before an SSA Judge
If you have been in front of an SSA Judge, what other information can you give, like date, result?
Who is your SSDI attorney?
Have you worked and paid FICA taxes 5 out of the last 10 years?
How much is the benefit you will get if approved for Social Security Disability Benefits?
Do you have a child or dependent under the age of 18?
DOB of your youngest child?
Worker's Compensation Information:
Do you have or recently had a worker's compensation claim?
What is the status of your worker's compensation claim?
If settled, when and for how much
Who is your WC attorney?
Did you get temporary WC checks?
If you got temporary checks, how much?
If you got temporary checks, when did they stop?
Have you filed for bankruptcy
If you filed for bankruptcy, when did you file?
Personal Injury Claim Information
Is the disability caused by a non-work car accident or related to a non-work injury caused by someone else?
If so, how and when?
Is there a PI case?
If there is a PI case, who is your PI attorney?
Disabled due to Military service?
Client will send in:
Source/Referral Final Information
For all claim types
How did you hear about us?
i.e., name of referral, website, or search engine
What type of source is this?
If we are unable to help you with your case, we may be able to provide you with an attorney referral who handles this type of case. Do we have your permission to share the information you provided with them to review and contact you directly?
Yes - Okay to refer and send the information provided to another attorney to contact me directly and provide me with the referring attorney’s contact information.
Yes - Okay to refer and send contact information only to another attorney to contact me directly and provide me with the referring attorney’s contact information.
No - Do not refer or send any information provided to another attorney.
Staff input: (ignore if you are a potential client)
Did the potential client ask for a specific attorney they would like to meet with?
If they asked for a specific attorney, which one?
Information Taken By:
Is this IQ Referred by an Attorney?
Originating Attorney Assigned in Act (Look up the attorney and by the law firm in Act to confirm the originating attorney)
The Agreed Co-Counsel Fee Percentage in Act
Default attorney to review Screening Sheet (Use "other" for multiple attys) or Select the Originating Attorney
Grade from NPV for IQ:
NPV from NPV for IQ:
Date/Time Screening Sheet originally taken
Reply to Email
Drag and drop files here
Choose a file
For potential clients: Please upload any documents you think we might need to review. Denial letters, approval letters, policy documents are very helpful. Please do not upload entire claim files or documents longer than 50 pages.
Attorney who reviewed Screening Sheet
Donna (SSD case)
Decision on Screening Sheet
Set up for intake
Auto set up for intake
TA - Review docs not rcvd
TA - Value, no refer
TA - Value & Refer Out
TA - Value & Other
TA - Lawtype Refer Out
TA - Ok to come back
TA - Other reason
TA - Refer SSDI Case
The date/time the final decision was made to either set up, turn away or IQ closed due to PC not sending in documents.
Date of the intake
Result of Intake
No Appt - No longer interested
No Appt - No response
PC canceled - No RS
Turnaway, ok to come back
Turnaway, not ok to come back
Turnaway with referral
If Contract offered, did they accept?
When was the contract signed?
Are all follow-up questions completed?
Who is confirming all follow-up questions are completed:
Should be Empty: