EBA PC Questionnaire

Potential Client Questionnaire
Background information for the Claimant

For all types of claim
Claimant's Name

Salutation:(Dr., Mr. or Ms.)First NameLast 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

CityState

Zip Code
Zip Code
What time zone are you in?

Other
Staff input: (ignore if you are a potential client)
Current Date

MonthDayYear
Date
Date of Birth of the Claimant

MonthDayYear
Date
Age (will calculate after DOB entered)
[Age Range prompt]
What type(s) of claim can we help you with?

Other
[Type for email]
If short term disability or SSDI, do you also have long term disability insurance coverage?
What is the status of your claim?

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?

MonthDayYear
Date
Is this the actual date on the letter or an estimate of when you were denied?
What date did you appeal the most recent denial?

MonthDayYear
Date
Is this the exact date you appealed?
Information about the disability

For LTD, STD, SSDI, and disability pension
When did you become disabled?

MonthDayYear
Date
Are you still working?
[still working prompt]
When did you last work?

MonthDayYear
Date
Has your employer offered you a severance agreement?
Tell caller:
What was your job before disability?
What types of medical conditions contribute to your 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?
[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?

Other
[optional] Additional notes about doctor's disability opinion:
What do you think about whether you can return to work?

Other
Information about Life Insurance Claim

Life Insurance
When did the insured person pass away

MonthDayYear
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?

Other
Is this a one-time procedure or treatment, or will you need to have the procedure or treatment again in the future?

Other
Have you already had the procedure/treatment?

Other
How much is the cost of the procedure/treatment?
Have you already paid any of the bill(s) for the procedure/treatment yourself?
How much have you paid toward the medical bills/procedure?
Are you eligible for Medicare or Medicaid?
Subrogation Claim Information
Nature of underlying claim

Other
What is the date of the original accident or injury?

MonthDayYear
Date
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?
What 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 has the insurer offered to take?
Can you fax or mail us 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 of the employer?
What is the pension dispute about?
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?
Does your doctor confirm the connection between the NFL and your impairment?
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?
What year was the last season you were an active player?
When did you file your application for NFL disability benefits?

MonthDayYear
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?
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?

Other
When did they say you needed to respond by?

MonthDayYear
Date
How much are they offering?
This should be the total dollar amount.
Is this the first buyout offer you have received?
Why did you decide against accepting the previous offer(s)?

Other
Do you have any other benefits from your employer or associated with your last employment?

Other
Long Term Care Claim Information
When did you begin to need long-term care treatment?

MonthDayYear
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?
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?
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

Other
What is the source of the money you received that created the overpayment?

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?
If yes, when did the benefit start?

MonthDayYear
Date
And when did the benefit end?

MonthDayYear
Date
Disability: What did they say was the reason for your denial?
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?

Other
Health Insurance: What did they say was the reason for your denial?

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?

Other
What is the reason that your pension benefit is less than it should be?

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?

Other
Estimated appeal deadline date

MonthDayYear
Date
Benefit Information

(Partial) LTD, STD, Life Insurance, Disability Pension
Do you know how much you would draw per month if approved?
How much is your monthly benefit?
Is this the benefit you get before or after taking out an offset for Social Security Disability benefits?
Disability: Do you know what percentage of your wages your disability benefit is?

Other
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 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?
[Filed for SSD prompt]
Have you filed for Social Security early retirement benefits?
[filed for early retirement]
Has your claim been denied by SSA?
Until SSA's denial, were you being paid social security disability benefits?
Have you appealed the denial you got from SSA?
Have you been before an SSA Judge?
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?
[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?
[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?
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

MonthDayYear
Date
Worker's Compensation Information:

For LTD
Do you have or recently had a worker's compensation claim?
What is the status of your worker's compensation claim?

Other
If settled, when?

MonthDayYear
Date
And how much was the settlement?
Who is your WC attorney?
Did you get temporary WC checks?
If you got temporary checks, when did they stop?

MonthDayYear
Date
If you got temporary checks, how much?
Bankruptcy information

For LTD
Have you filed for bankruptcy
If you filed for bankruptcy, when did you file?

MonthDayYear
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?
If so, how and when?
Is there a Personal Injury case?
If there is a Personal Injury case, who is your Personal Injury attorney?
Military

For LTD
Disabled due to Military service?
Miscellaneous
Additional notes:
The potential client will send in:

Other
Based on your conversation with the PC, rate their demeanor
Any indication the PC was deciding between multiple attorneys?
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?

Other
What is the name of the person who referred you?
What led you to our website:

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?

Other
Checkpoint 1
[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?
If they asked for a specific attorney, which one?
Post-Interview information:
Information Taken By:

Other
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 Jotform (Use "other" for multiple attys)or Select the Originating Attorney. Include KDG on all ERISA Subrogation cases.

Other
Grade from NPV for IQ:

Other
NPV from NPV for IQ:
[Grade element for email]
Date/Time Screening Sheet originally taken

MonthDayYear
Date
Hour MinutesAM/PM Option
Reply to Email
example@example.com
File Upload

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.
Cancelof
Follow-up information
Attorney who reviewed the Jotform
Jotform Decision
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.

MonthDayYear
Date
Hour MinutesAM/PM Option
Intake Attorney
Date of the first intake

MonthDayYear
Date
Result of Intake
Total Number of Intake Appointments
If Contract offered, did they accept?
When was the contract signed?

MonthDayYear
Date
IQ Referred to Attorney
What is the referral fee in ACT for the attorney to whom we referred the PC?
Did the attorney take the referred case?
If the attorney took the referred case, did we open the TA IQ Case to a RF Case in ATO?
Are all follow-up questions completed?
Who is confirming all follow-up questions are completed:
Name
Blank Field
Summary of Auto-Setup Criteria Evaluated
Should be Empty:

Potential Client Questionnaire

Background information for the Claimant

Information about the disability

Information about Life Insurance Claim

Health Insurance Claim Information

Subrogation Claim Information

Pension or Retirement Claim Information

NFL Claim Information

Information about the insurance policy

Buyout Offer Information

Long Term Care Claim Information

Overpayment Information

Claim Information

Benefit Information

Social security claim

Worker's Compensation Information:

Bankruptcy information

Personal Injury Claim Information

Military

Miscellaneous

Source/Referral Final Information

Post-Interview information:

Follow-up information