Potential Client Questionnaire
Background information
For all types of claim
Name
*
Salutation:(Dr., Mr. or Ms.)
First Name
Last Name
Suffix
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Current Date
-
Month
-
Day
Year
Date
Date of Birth
*
/
Month
/
Day
Year
Date
Age (will calculate after DOB entered)
What type of claim do you need help with?
*
LTD/IDI
STD
Life Ins.
Health
LTC
Subrogation
Pens./Ret.
SSD
Other
If short term disability or SSDI, do you also have long term disability insurance coverage?
Yes
No
Not sure
What is the status of your claim?
Denied, have not appealed
Denied, appeal filed and pending
Denied, final denial received
Not applied yet
Application pending
Other
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?
Yes
No
Name(s) and Type(s) of doctors who support disability?
Does your doctor say you will never be able to go back to work?
Yes
No
[optional] Additional notes about doctor's disability opinion:
Do you think you will be able to go back to work?
Yes
No
If you think you might return to work, when and how?
Information about Life Insurance Claim
Life Insurance
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)?
Yes
No
How much have you paid toward the medical bills/procedure?
Are you eligible for Medicare or Medicaid?
Yes
No
Subrogation Claim Information
Nature of underlying claim
Car Wreck
Medical Malpractice
Other
What is the date of the original accident or injury?
Are you represented by an attorney for the underlying claim
Yes
No
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?
Yes
No
What court?
Has there been a settlement offer in the underlining case?
Yes
No
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?
Yes
No
How much have they offered to take?
Can they fax or mail in the letter from the health insurance company?
Yes
No
Pension or Retirement Claim Information
Who is pension from?
Union
Employer
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?
Please Select
Work
Individually
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?
Permanent
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?
Yes
No
If yes, what is it?
Claim Information
(Partial) LTD, STD, life insurance, Health and disability pension
Have you received benefits already?
Yes
No
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
Pre-existing condition
No coverage
Other
Life Insurance: What did they say was the reason for your denial?
Not insured
Not eligible for coverage
Exclusion eliminates coverage
Other
Health Insurance: What did they say was the reason for your denial?
Investigational/experimental
No coverage
Exclusion applies
Out of network
Other
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?
Yes
No
If you filed the appeal, what date did you file it?
Benefit Information
(Partial) LTD, STD, Life Insurance, Disability Pension
Do you know how much you would draw per month if approved?
Yes
No
If yes, how much?
Is this before or after SS offset
Please Select
Before
After
"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?
60%
50%
40%
Defined Benefit
Don't know
Other
Life Insurance: Do you know how much the life insurance would be?
Yes
No
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?
Yes
No
Don't know
Life Insurance: Were the deceased person's wages paid by salary or hourly?
Salary
Hourly
Disability: Before you became disabled, were you paid salary, hourly, or commission?
Salary
Hourly
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?
Yes
No
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
Yes
No
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?
Yes
No
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?
Yes
No
DOB of your youngest child?
Worker's Compensation Information:
For LTD
Do you have or recently had a worker's compensation claim?
Yes
No
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?
Yes
No
If you got temporary checks, how much?
If you got temporary checks, when did they stop?
Bankruptcy information
For LTD
Have you filed for bankruptcy
Yes
No
If you filed for bankruptcy, when did you file?
Personal Injury Claim Information
For LTD
Is the disability caused by a non-work car accident or related to a non-work injury caused by someone else?
Yes
No
If so, how and when?
Is there a PI case?
Yes
No
If there is a PI case, who is your PI attorney?
Military
For LTD
Disabled due to Military service?
Yes
No
Miscellaneous
Additional notes:
Client will send in:
Denial
Policy
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?
*
Please Select
Attorney
Internet-Website
Internet-Google
Internet-Other
Client Referral
Friend
Family
Doctor
TV
Not applicable
(Pick one)
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.
Other
Staff input: (ignore if you are a potential client)
Did the potential client ask for a specific attorney they would like to meet with?
*
Yes
No
If they asked for a specific attorney, which one?
Post-Interview information:
Information Taken By:
*
Alicia
Barbara
Donna
Jeffrey
Molina
Sophie
Stacey
Terrance
PC completed
Other
Is this IQ Referred by an Attorney?
*
Yes
No
Originating Attorney Assigned in Act (Look up the attorney and by the law firm in Act to confirm the originating attorney)
*
ELB
HTE
ACD
NAB
KDG
KEB
None
The Agreed Co-Counsel Fee Percentage in Act
*
Default attorney to review Screening Sheet (Use "other" for multiple attys) or Select the Originating Attorney
*
ACD
KDG
NAB
Donna Green
Other
Grade from NPV for IQ:
*
A+
A
B
C+
C
D
NA
Other
NPV from NPV for IQ:
*
Date/Time Screening Sheet originally taken
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Reply to Email
example@example.com
File Upload
Browse Files
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.
Cancel
of
Preview PDF
Save
Submit
Follow-up information
Attorney who reviewed Screening Sheet
Please Select
Audrey
Eric
Hudson
Kaci
Noah
Donna (SSD case)
Auto Set-Up
Auto TA
Decision on Screening Sheet
Please Select
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.
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Intake Attorney:
Please Select
Audrey
Kaitlyn
Hudson
Kaci
Noah
Eric
Date of the intake
-
Month
-
Day
Year
Date
Result of Intake
Please Select
No Appt - No longer interested
No Appt - No response
PC canceled - No RS
Offered contract
Turnaway, ok to come back
Turnaway, not ok to come back
Turnaway with referral
If Contract offered, did they accept?
Yes
No
When was the contract signed?
-
Month
-
Day
Year
Date
Are all follow-up questions completed?
Yes
No
Who is confirming all follow-up questions are completed:
Name
Save
Submit
Should be Empty: