Do I Have a Case?

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Your Name

Email Address:

Phone Number:

Date of Birth

Briefly describe your disability (list all medical conditions involved):

Date Disability Began (Approximate)

Are you currently receiving Social Security benefits? Yes No

If not, Have you applied before? Yes No N/A

What was your annual salary from your last employer?

If you have received long-term disability benefits, what is (was) the monthly amount?

What was your last occupation?

Please Read Carefully:

I am submitting this questionnaire and attachments for review by Mehr Disability Law Group. I understand the following:

1. That the submission of information is for review only and that there will be no charge for this review.

2. Mehr Disability Law Group and I have not entered into an attorney-client relationship and are not acting as my attorney unless and until a formal, written Retainer Agreement has been signed both by me and by a representative of Mehr Disability Law Group. No decision has yet been made on whether Mehr Disability Law Group will take my case and there is no guarantee that the firm will accept my case.

3. Further information may be requested in order for Mehr Disability Law Group to reach a decision.

4. It takes time to review the material submitted and to make any reply or decision. Because no attorney-client relationship has yet been established, I will be responsible until I am notified otherwise to meet all necessary deadlines and time frames applicable to my claim; and I acknowledge that I have not received any representations or legal opinions with respect to any time frames or deadlines that may be applicable to my claim.

I have read and agree to all of the above conditions

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ERISA, Disability Attorney, Insurnace Bad Faith attorney for Lexington, Louisville, Frankfort, Paducah, Pikeville, London, Ashland, Campbellsville, Morehead, Murray, Richmond, Covington, Bowling Green, Stanford, Irvine, Newport, Florence, Erlanger, Fayette County, Jefferson County, Kenton County, Pike County, Estill County, Lincoln County, Laurel County Kentucky as well as Federal Court, US District Court and the Kentucky Court of Appeals.

Mehr Disability Law Group has successfully represented clients against Hamilton Mutual Insurance, Home Insurance Company, Kentucky National Insurance, Kentucky Farm Bureau Insurance, Minnesota Life, Liberty Mutual, Progressive Northern Insurance, State Auto and National Casualty Insurance. MDLG is part of the Austin Mehr Law Offices.

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