Long Term Disability Assessment Questionnaire
Please fill out the sections accurately to assist with your LTD claim evaluation.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Section 1: The Basics
Were you working full-time when your disability began?
*
Yes
No
What type of coverage do you have?
*
Individual policy
Group plan through employer
Not sure
What is your current claim status?
*
Denied at initial application
Benefits recently cut off
Not sure
Section 2: The 'Total Disability' Evidence
Primary medical condition or diagnosis
*
Does your treating physician support that you cannot work?
*
Yes
No
Unsure
Current prescribed treatment plan
Medication
Physical therapy
Occupational therapy
Counseling or psychotherapy
Specialist care
Surgery follow-up
Lifestyle modifications
Other
Section 3: The 'Change in Definition' (Crucial for LTD)
If applicable, how many years have you been receiving LTD benefits?
Are you approaching the 2-year “Any Occupation” review mark?
*
Yes
No
Not sure
Upload any decision letter pertaining to your claim
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