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Disability Web Intake Form

Name *

Date of Birth

Cell Phone *

Home Phone

Work Phone

Email Address *

Street Address

City *

Province

Postal Code

If you are contacting us on behalf of someone else, please provide that person’s full name, date of birth and your relationship to that person

Description of disability *

When disability started

Was there an incident that caused the disability to start, if yes, please describe:

When stopped working

Name of disability insurer

Is the disability policy through your employer? Yes No

What is the date that you applied for disability benefits?

What is the amount of your disability benefit?

Did your insurer accept your application and pay you any disability benefits? Yes No

If yes, for how long did were you paid disability benefits?

What reason did your insurer provide for terminating or denying you disability benefits? *

What is the date that your insurer denied or terminated your disability benefits? *

What was the date of your last disability benefit payment?

What is the name of your employer?

Description of your employment tasks and duties?

Describe how your disability prevents you from doing your job?

What is your employment income per year

Are you part of a union? Yes No

Have you filed a grievance with your union for the non-payment of your disability benefits? If yes, what is the response?

Are you planning on returning to work in the future? Yes No

Have you applied for CPP-D benefits? Yes No

If yes, date you applied for CPP-D benefits?

Was the application approved or denied? N/A Approved Denied

What is the date of your CPP-D approval or denial?

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