Law Offices of Mark F. Seltzer & Associates - Disability Insurance Law: Do I Have a Case or Well-Founded Claim?

Contact us for a Consultation If you are considering filing a disability claim, need help maintaining a claim, have had a claim denied or terminated, or need assistance with your disability insurance company.

First Name:

Last:

Address 1:

Adr 2:

City:

State:

Zip:

Phone:
(day)

Phone:
(eve.)

Email:

Date of Birth:
Month:		Day:		Year:

Social Security Number:
(no spaces &/or dash)

Occupation:
(specialty)

Date of Disability:
Month:		Day:		Year:

Disability Insurer(s):

Policy Number(s):

Policy Effective Date(s):

Monthly Benefit(s):

Type of Policy:

Group Individual

Benefit Period(s):

Have you ever received disability benefits from this policy or any other policy?

Yes No

Disabling Condition(s):

Have you ever been disabled before?

Yes No

If so, when?