Free Case Evaluation - Disability Claims

(Complete this form for Disability Insurance, ERISA Disability, Social Security Disability/SSI and Veteran's Disability Benefit Cases)

*Name:
*Address:
*City:
*State:	Choose One AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Zip:
*E-mail address:
*Home Phone:
Business Phone:
Cellular or Pager:
Facsimile:
Claimant Information
For whom are you inquiring?	Self Spouse Child Parent Relative Friend
Claimant's date of birth	mm 01 02 03 04 05 06 07 08 09 10 11 12 dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 yyyy 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Marital status	Select Single Married Separated Divorced
Is the claimant working?	Yes, my occupation is   No, my prior occupation was   Date that claimant last worked
What are the present means of support?	Select Spouse Pension Short/Long Term Disability Public Assistance Workers Compensation Other
Does the claimant have a lawyer?	No Yes, for which claim(s)?
Long/Short Term Disability Claims Process (skip if not applicable)
Name of insurer
Are you receiving benefits?	SelectYes No
Amount of monthly benefit to be received
Where are you in the process?	Have not applied yet Initial denial Filed appeal, no decision yet Appeal denied, have another Appeal denied, must file lawsuit
What was the date of your last denial?	mm 01 02 03 04 05 06 07 08 09 10 11 12 dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 yyyy 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Social Security Claims Process (skip if not applicable)
Have you applied for Social Security Disability?	Select Yes No
Have you had a hearing for Social Security Disability?	Select Yes No
After the hearing, were you denied Social Security Disability Benefits?	Select Yes No
If you were denied benefits, have you filed an appeal to the Appeals Council?	Select Yes No
Case Description
Please describe your case

Tucker & Ludin, P.A. | Main Office: 13577 Feather Sound Drive, Suite 300 | Clearwater, FL 33762
Tampa: 2202 N West Shore Blvd, Suite 200, Tampa, FL 33607
Phone 727-572-5000 | Tampa: 813-594-5000 | info@tuckerludin.com