CLIENT INQUIRY - ERIC BUCHANAN AND ASSOCIATES, PLLC

If you would like a call from one of our team members, please provide the following information so we may serve you more efficiently.

Contact Information
*required information
*Name:
*Phone:
*Email:
City:
State:
Policy Information
Policy Type:
Through Your Employer (Group)
By You Personally (Private)
Insurance Company
Monthly Benefits Owed by Insurance Company:
Monthly Social Security or Workers' Comp Payment, if any:
Age:
Has your claim been denied: Yes No
If it has been denied, what is the reason given for the denial?

If not, what is the status of your claim?

If your policy is through your employer and it was denied,
a) have you appealed? Yes No
b) if you have not appealed, how much time do you have to appeal?
What is the nature of your disabling condition?

Have you filed a Social Security Disability claim? YesNo
If you filed a Social Security Disability claim, what is the status?

Any additional information you wish us to consider:

How did you find us?:
If Internet search, what search engine did you use?
Newspaper or Magazine Article:
Personal referral:
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Disability Insurance Attorney