Canada Pension Disability (CPP) Case Assessment Questionnaire
Please provide your details to assess your eligibility and claim status.
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
Part 1. Basic Eligibility
Are you currently between 18 and 65 years old?
*
Yes
No
Are you currently receiving a CPP retirement pension?
*
Yes
No
If yes, how many months have you been receiving the CPP retirement pension?
Part 2. Contribution History
Years worked and contributed to CPP in the last 6 years
*
Have you contributed to CPP for at least 25 years total?
*
Yes
No
Did you stop working or have low earnings to care for a child under age 7?
*
Yes
No
Part 3. Medical Severe and Prolonged Test
Primary diagnosis
*
Does this condition prevent any type of substantially gainful work?
*
Yes
No
Is the condition expected to be long-term and of indefinite duration, or likely to result in death?
*
Long-term and indefinite duration
Likely to result in death
No
Are you following the prescribed treatment plan from your doctors? If yes, briefly describe the treatment plan and any specialists, medication, or therapy involved.
Part 4. Personal Circumstances
Highest level of education
*
Please Select
Less than high school
High school diploma or equivalent
Some college
College diploma
Bachelor's degree
Graduate degree
Other
Would language barriers impact ability to find alternative work?
*
Yes
No
Primary work experience
*
Part 5 Current Claim Status
Current Employment Status
*
Not working
Working full-time
Working part-time
Volunteer work
Self-employed
On leave
Other
Application History
*
First-time application
Previously applied and denied
Currently appealing a denial
Other
Date of Most Recent Denial Letter
-
Month
-
Day
Year
Date
Please upload decision letter if you are currently appealing a denial letter
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