Potential Client Questionnaire
Background information for the Claimant
For all types of claim
Claimant's Name
*
Mr.
Mrs.
Ms.
Miss
Dr.
Salutation:(Dr., Mr. or Ms.)
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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
Zip Code
What time zone are you in?
Pacific Time Zone
Mountain Time Zone
Central Time Zone
Eastern Time Zone
Alaskan Time Zone
Hawaiian Time Zone
Other
Staff input: (ignore if you are a potential client)
Current Date
-
Month
-
Day
Year
Date
Date of Birth of the Claimant
*
/
Month
/
Day
Year
Date
Age (will calculate after DOB entered)
[Age Range prompt]
What type(s) of claim can we help you with?
*
LTD/IDI
Overpayment
STD
SSD
Life Ins.
LTD/IDI Buyout
Health Ins.
LTC
NFL Disability
Subrogation
Pens./Ret.
Other
[Type for email]
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?
I have not applied yet
I have applied and no decision has been made on my application yet
Currently approved and receiving benefits but concerned about an issue
Denied, have not yet appealed
Denied, appeal filed and it is pending
Denied, final denial received but have not filed suit in Court yet
My claim is in Court already
Other
Would you tell us what it is that you are needing our help with in as much detail as possible?
Because you have not been denied yet, this helps our attorneys know what you are needing help with.
[Auto-Has the claim been denied?]
What is the date of the most recent denial?
-
Month
-
Day
Year
Date
Is this the actual date on the letter or an estimate of when you were denied?
Exact date
Estimate
What date did you appeal the most recent denial?
-
Month
-
Day
Year
Date
Is this the exact date you appealed?
Exact date
Estimate
Information about the disability
For LTD, STD, SSDI, and disability pension
When did you become disabled?
-
Month
-
Day
Year
Date
Are you still working?
Yes
No
[still working prompt]
When did you last work?
-
Month
-
Day
Year
Date
Has your employer offered you a severance agreement?
No
Yes, and I have already signed it
Yes, but I haven't signed it yet
Tell caller:
What was your job before disability?
What types of medical conditions contribute to your disability?
I only have physical health conditions
I only have mental health conditions
My physical health condition(s) are primary but I also have mental health conditions
My mental health condition(s) are primary but I also have physical conditions
I have physical and mental health conditions and are roughly equal parts of my disability
Is claim mostly Mental and Nervous?
[Mental/Physical condition prompt]
Would you describe your disabling medical conditions in as much detail as possible?
Do you have a doctor(s) who says you are disabled?
Yes
No
[Doctor support prompt]
Name(s) and Type(s) of doctors who support disability?
Has your doctor told you that you will ever be able to go back to work?
Yes, my doctor thinks I will be able to go back to work
No, my doctor does not think I will be able to return to work
My doctor has not said (or does not know)
Other
[optional] Additional notes about doctor's disability opinion:
What do you think about whether you can return to work?
Maybe some day
Yes, I expect to return soon
Yes, but it will be a while before I can
I do not think it is likely
I tried but could not
Other
Information about Life Insurance Claim
Life Insurance
When did the insured person pass away
-
Month
-
Day
Year
Date
What caused them to pass away?
Health Insurance Claim Information
What procedure or treatment is the insurance company denying coverage/payment for?
What kind of doctor is prescribing or recommending the procedure/treatment?
Surgeon
Neurologist
Psychiatrist/psychologist
Rheumatologist
General Practitioner (PCP)
Oncologist
Opthalmologist
Endocrinologist
Cardiologist
Other
Is this a one-time procedure or treatment, or will you need to have the procedure or treatment again in the future?
Single procedure/treatment
I will need the procedure/treatment once more more
I will need the procedure/treatment between 2 and 5 more times
I will need the procedure/treatment between 6 and 12 more times
I need this procedure/treatment regularly from now on
Other
Have you already had the procedure/treatment?
Yes, I have already had the procedure/treatment
No, I am waiting on the insurer's approval before going forward
Other
How much is the cost of the procedure/treatment?
Have you already paid any of the bill(s) for the procedure/treatment yourself?
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?
-
Month
-
Day
Year
Date
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 has the insurer offered to take?
Can you fax or mail us 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 of the employer?
What is the pension dispute about?
I am being denied disability pension benefits
I am being denied retirement pension benefits
My pension benefits are less than they should be
What is the benefit being denied?
How much is your pension/retirement benefit?
NFL Claim Information
How is your impairment related to your time in the NFL?
My impairment arose while I was an active NFL player and during NFL-football activities
My impairment arose while I was an active NFL player, but not during NFL-football activities
My impairment arose after I ended my NFL career.
Does your doctor confirm the connection between the NFL and your impairment?
Yes
No
I do not know; have not asked
What team(s) did you play for in the NFL?
How many NFL seasons were you employed as an active player on an NFL roster for at least 3 games?
One or two seasons
Three seasons
Four seasons
Five or more seasons
What year was the last season you were an active player?
When did you file your application for NFL disability benefits?
-
Month
-
Day
Year
Date
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?
Through my 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?
Buyout Offer Information
How were you given the offer?
In a letter
Over the phone
Other
When did they say you needed to respond by?
-
Month
-
Day
Year
Date
How much are they offering?
This should be the total dollar amount.
Is this the first buyout offer you have received?
Yes
No
Why did you decide against accepting the previous offer(s)?
They did not offer enough
I prefer to get monthly benefits
The advice of friends/family
I did not understand the offer
Other
Do you have any other benefits from your employer or associated with your last employment?
Health insurance
Pension benefits
Life insurance
Other
Our attorneys charge a flat fee of $500 to review buyout offer documents and schedule an appointment to discuss and give advice about the offer; are you willing and able to pay this fee before the appointment?
Yes
Yes, and my insurer included in its offer that it will pay all or part of this fee
No
Long Term Care Claim Information
When did you begin to need long-term care treatment?
-
Month
-
Day
Year
Date
What is your health condition that requires long-term care?
What doctor says you are disabled and need long-term care?
Is the long term care likely permanent or temporary?
Permanent
Temporary
If temporary, how long do you 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?
Overpayment Information
What is the type of benefit the insurer is claiming that it overpaid you and wants you to pay back
Long Term Disability benefits
Health Insurance benefits
Life Insurance benefits
Pension benefits
Other
What is the source of the money you received that created the overpayment?
Social Security Disability benefits
Personal injury lawsuit
Worker’s Compensation claim
Severance
Other Long Term Disability policy
Other
How much money does the insurer say that they overpaid you?
Why do you think you do not owe all (or part) of what the insurer says you were overpaid?
Claim Information
(Partial) LTD, STD, life insurance, Health and disability pension
Have you received benefits already?
Yes
No
If yes, when did the benefit start?
-
Month
-
Day
Year
Date
And when did the benefit end?
-
Month
-
Day
Year
Date
Disability: What did they say was the reason for your denial?
They say I am not disabled
They say I did not get them needed information in time
They say my disability is due to a pre-existing condition
They say I am not covered under the policy or the policy is invalid
They say my policy limits benefits for my disabling condition (e.g., max 24 months for mental and nervous, self-reported symptoms, etc.)
Denied due to disability or untimely information (not pre-ex, no coverage, limited period, or 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?
This question is for long term care, LTC, or NFL
What is the reason for your pension benefits being denied?
They say I am not disabled and so am not eligible for disability pension
They say that I do not have enough work credits/hours/years to qualify
Other
What is the reason that your pension benefit is less than it should be?
They say that I have less work credits/hours/years than I actually have
They are misreading/interpreting the plan
Other
Why is that reason wrong?
Life Insurance, Pre-Existing Condition, Health Insurance, or NFL
What is the deadline to appeal listed in your denial letter?
180 days after receiving the letter
90 days after receiving the letter
60 days after receiving the letter
No deadline listed in the letter
Other
Estimated appeal deadline date
-
Month
-
Day
Year
Date
Benefit Information
(Partial) LTD, STD, Life Insurance, Disability Pension
Do you know how much you would draw per month if approved?
Yes
No
How much is your monthly benefit?
Is this the benefit you get before or after taking out an offset for Social Security Disability benefits?
Before taking out the offset; the amount above does not account for any SSD offset
After taking out the offset; the amount above already accounts for SSD's offset.
There is no offset for SSD; I have a private (IDI) policy that does not offset for SSD.
Disability: Do you know what percentage of your wages your disability benefit is?
70%
60%
50% or less
Defined Benefit (the policy says a specific $ amount)
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 your yearly income?
If paid by the hour, what was your hourly wage?
If hourly wage, how many hours per week? (on average)
Number of hours only (don't include "hrs." or "hours")
Calculated Yearly Wage from hourly
Yearly Wage (final)
Social security claim
For LTD, SSD
Have you filed for Social Security?
Yes
No
[Filed for SSD prompt]
Have you filed for Social Security early retirement benefits?
Yes
No
[filed for early retirement]
Has your claim been denied by SSA?
Yes
No
Until SSA's denial, were you being paid social security disability benefits?
Yes
No
Have you appealed the denial you got from SSA?
Yes
No
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 the date of the hearing, the result?
Are you currently, or have you ever been helped by someone with your Social Security claim?
I have never been represented
I was represented but am not now
Someone represents me but I am not satisfied with them
Someone represents me and I am happy with them
[Are you currently represented for SSD?]
Who is or was your SSDI representative?
This can be an individual representative, a company, or a law firm.
If you are not happy with your current SSD representative, why?
Have you worked and paid taxes on your income 5 out of the last 10 years?
Yes
No
[SSDI eligible prompt]
SSD Refer Check ("Yes" = referrable)
Will be "No" if the claimant has been cessed, is receiving early retirement, or is still represented
Do you know how much Social Security will pay you if you are approved for Social Security Disability Benefits?
Yes, from a recent PEBES (Personal Earnings and Benefit Estimate Statement)
Yes, from my SSD attorney
Yes, other
No, I don't know
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
-
Month
-
Day
Year
Date
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?
Injured, but not yet filed claim
Filed Claim, no decision yet
Claim decided, not settled yet
Settlement already obtained
Other
If settled, when?
-
Month
-
Day
Year
Date
And how much was the settlement?
Who is your WC attorney?
Did you get temporary WC checks?
Yes
No
If you got temporary checks, when did they stop?
-
Month
-
Day
Year
Date
If you got temporary checks, how much?
Bankruptcy information
For LTD
Have you filed for bankruptcy
Yes
No
If you filed for bankruptcy, when did you file?
-
Month
-
Day
Year
Date
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 Personal Injury case?
Yes
No
If there is a Personal Injury case, who is your Personal Injury attorney?
Military
For LTD
Disabled due to Military service?
Yes
No
Miscellaneous
Additional notes:
The potential client will send in:
Denial
Policy
Severance Agreement
Other
Based on your conversation with the PC, rate their demeanor
1 - Hostile
2 - Unpleasant
3 - Average
4 - Pleasant
5 - Sweetheart
Any indication the PC was deciding between multiple attorneys?
Yes
No
What details about the PC's demeanor caused you concern or to think they were considering multiple attorneys?
Source/Referral Final Information
For all claim types
How did you hear about us?
*
Attorney Referral
Former Client Referral
Doctor Referral
Internet-Website
Internet-Google
Other
What is the name of the person who referred you?
What led you to our website:
Google
Other search engine
Facebook
LinkedIn
Youtube
Other
Do you remember what you searched for?
What website led you to us?
i.e., name of referral, website, or search engine
Auto-Setup code
LTD Auto-Setup Label
LTD Auto-Set-up decision
This auto-populates if an auto-setup is appropriate
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.
No - Do not refer or send any information provided to another attorney.
Other
Checkpoint 1
Inactive
Active
[Auto: Is the IQ in Chattanooga or North Georgia area?]
Who is the Defendant?
[Email Lead]
[auto-setup/SS attorney/intake attorney]
SSD Referral ID
SSD Referral ID, Non-Preferred, or NOSSCR
SSD Referral Info
Social Security Disability Referral Decision
Social Security Disability Referral Prompt
[Email-Referral or Auto Setup Lead]
[Email-Referral or Auto Setup Content]
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?
*
ELB
ACD
NAB
KDG
KEB
Post-Interview information:
Information Taken By:
*
Terrance
Aya
Emily
Molina
Lilly
Sophie
Jeffrey
Cambria
William
Ren
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
ACD
NAB
KDG
KEB
None
The Agreed Co-Counsel Fee Percentage in ACT
*
Default attorney to review Jotform (Use "other" for multiple attys)or Select the Originating Attorney. Include KDG on all ERISA Subrogation cases.
*
ACD
KEB
KDG
NAB
ELB
Other
Grade from NPV for IQ:
*
A+
A
B
C+
C
D
NA
Other
NPV from NPV for IQ:
*
[Grade element for email]
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.
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Follow-up information
Attorney who reviewed the Jotform
Please Select
Audrey
Eric
Kaci
Kaitlyn
Noah
Donna (SSD case)
Auto Set-Up
Auto TA
Jotform Decision
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 - Lawtype - no refer
TA - Ok to come back
TA - Other reason
TA - Refer to SSD Atty
TA - Refer SSDI Case to NOSSCR
The date/time the final decision was made to either set up, turn away, or close the IQ due to PC not sending in documents.
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Intake Attorney
ACD
ELB
KEB
KDG
NAB
Date of the first intake
-
Month
-
Day
Year
Date
Result of Intake
Please Select
No Appt - No longer interested
No Appt - No response
Paid Consultation Only
PC canceled - No RS
Offered contract
Turnaway, ok to come back
Turnaway, not ok to come back
Turnaway with referral
Turnaway - Refer to NOSSCR
Requested additional information
Total Number of Intake Appointments
Please Select
1
2
3
4
If Contract offered, did they accept?
Yes
No
When was the contract signed?
-
Month
-
Day
Year
Date
IQ Referred to Attorney
Please Select
Seth Holliday
Donna H. Green
Kantor & Kantor
Jeremy Bordelon
Sigman, Janssen, Sewall, Pitz & Burkham - (Anstasia Burkham)
Tucker Law Group
Chisholm Chisholm & Kilpatrick
McCullough, Wareheim & LaBunker
Apex Disability Law
Forrest Jackson
Jason Khattar
Parmele Law Firm
Mikel & Hamill
Brian Smith - Wettermark, Keith
Karen Jernigan
Andrew Reichardt
Frank Midgley
Fred Daley
Charles Martin
Katherine Sullivan
Paul McChesney
Lisa Saar
Donna Simpson
Josephine Gerrard
Nick Lavella
Chris Latham
Sam Roberti
Brian Canupp
Tracey Pate
Jim Joyce
Andrew Sapiro
Bill Matthews - Gulf South Disability
Eric Bolves - The Legal Center
Warren Harris - Harris & Riviere
Tom Scully
Lance Tillinghast
John Capista
Joshua Eyestone
Laurie Baron
Thomas Stewart
Erick Bowman
Scott Wilson
Stephanie Joy
Amar Raval
Bob June
Tiffany Ours
Michael Hartup
Maren Bam
James Rinck
Benjamin Glass
David Bary
Tim Crosby
Dacey Romberg
Jonathan Williams
Larry Rohlfing
Denise Tataryn
Jacqulyn Jones
Vanessa Kuhn
Jared Rada
John Williams
Julie Hall
Frank Tuzzolino
Beth Alpert
Joel Zelkowitz
George Piemonte
Jennifer Solomon
John Lander
Ivan Katz
Jennifer Danish
J. Anklowitz
Ashley Loy
Jason Jenkins
Shawn McDermott
Jeffrey Flynn
Corey Luedeman
David Hicks
Jan Fisher
Jeffrey Berzowski
Kimberly Syfrett
Mac Downs
Maggie Schott
Michael Friedman
Richard Feingold
Robert Cornett
Tim Geary
Gian Fanelli
What is the referral fee in ACT for the attorney to whom we referred the PC?
0%
10%
15%
20%
25%
33 1/3%
Did the attorney take the referred case?
Yes
No
Offered contract
If the attorney took the referred case, did we open the TA IQ Case to a RF Case in ATO?
Yes
Are all follow-up questions completed?
Yes
No
Who is confirming all follow-up questions are completed:
Name
Blank Field
Summary of Auto-Setup Criteria Evaluated
Save
Submit
Should be Empty: