If you would like a NO COST initial consultation, please answer the questions below to the best of your ability. The more detailed info you provide the better we will be able to discuss your matter with you. We will respond to your inquiry after reviewing the info below.

Your First Name:
Your Last Name:
Phone Number:
Email:
Alternate Number / Message Number:
Is this inquiry about you or someone else?
If someone else, what is your relationship to the applicant?

THE FOLLOWING REQUESTED INFO RELATES TO THE APPLICANT (the person who will be or has filed for Long Term Disability benefits).

Name:
Date of Birth:
Address:
City:
State:
Zip Code:
Phone Number:
E-mail address:
Are you presently receiving disability benefits:	Yes   No
If yes, what type of benefits are you receiving?
Is your claim under a personal, group (provided through employer) or State plan?	personal    group    Arizona State Retirement System    other:
Date Last Worked:
Reason you stopped working:
What was your last job?
What medical conditions prevent you from working?
Has a doctor told you that you shouldn't work?
Have you filed a claim?	Yes   No
Would you like an attorney to call you for a no cost initial consultation?	Yes   No
If you have filed a claim, has it been accepted?	Yes   No
If your claim has been denied, what is the date of the most recent denial?
Have you appealed this denial and if so, when did you last appeal?
Other comments:
Questions:

   I understand that submitting this form does not create an attorney-client relationship. I further understand that responses to my inquiry SHOULD NOT BE CONSIDERED SPECIFIC LEGAL ADVICE AND MAY NOT BE RELIED ON FOR MY INDIVIDUAL CASE. I understand that the lawyers at SCHIFFMAN LAW OFFICE, P.C. have not agreed to represent me by responding to initial or follow-up inquiries and prior to legal representation both the client and an attorney of the firm must sign a fee agreement and a formal notice of representation or appearance. I understand that the lawyers at SCHIFFMAN LAW OFFICE, P.C. do not presently have enough detailed information about the status of my particular matter and that I remain responsible for meeting any deadlines or statutes of limitation until an attorney of the firm has formally agreed to represent me and entered an appearance in my specific matter.

We respect your privacy. The info you provide will be kept confidential. Thanks for your inquiry.