NEW CLIENT - DISABILITY RETIREMENT

BACKGROUND

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Appointment Date and Time

How were you referred to us?

If you selected Friend/Family Member, Event, Attorney, Community Organization, or Other for the prior question, please specify where you heard about us.

Name

First Last

Address

Cell Phone/Home No.

Email Address:

Date of Birth:

SSN:

Primary Language:

Need Interpreter?

Do you have a smart phone?

Do you have texting?

Emergency contact (Name, Relationship, Cell Phone)

Please state the name of your Employer:

Date of hire:

Last day of work:

Your job title and department:

How much did you annually earn in your job?

Do you have an attorney? If so, for how long and why are you seeking additional legal counsel?

If you have retained a WC attorney to help you pursue WC benefits, please state the attorney’s name:

STATUS OF YOUR DISABILITY APPLICATION

If you have already applied for disability retirement benefits, what is the date you filed the application?

Have you been examined by a physician(s) on behalf of the retirement system? If so, please state the name(s), address(es) and date(s) of that exam:

Have you completed an analysis of your job duties for the retirement system?

If your disability retirement application been referred to an evidentiary hearing, please state the date of the hearing

If an evidentiary hearing has been set, please state the name of the hearing officer assigned to your case

BASIS FOR DISABILITY RETIREMENT APPLICATION

Please state all medical conditions that you believe support your request for disability retirement benefits:

If you maintain that some or all of these conditions were caused by work, please describe their connection to work:

If you have received treatment for these conditions, please identify the health care provider(s) who has treated you, his or her specialty, and the dates of treatment:

If you have been examined by an Agreed Medical Examiner (AME) or Panel Qualified Medical Examiner (PQME) in your WC claim, please identify the name of the AME/PQME, his or her specialty, and the date(s) of examination:

REASONABLE ACCOMMODATIONS

Before your last day of work, please describe any and all accommodations that your employer provided that would allow you to perform your work:

If there are accommodations that you believe (not what your employer is willing to do) that would allow you to return back to work, please describe those accommodations:

If your employer has told you that it cannot accommodate your work limitations, please identify the date it told you that information and how it conveyed it to you; e.g., over the phone, in a meeting, by letter?

Have you ever participated in a meeting with your employer to determine what accommodations or modifications or alternative jobs are available to you that would allow you to return to work?

Disability Retirement

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BACKGROUND

STATUS OF YOUR DISABILITY APPLICATION

BASIS FOR DISABILITY RETIREMENT APPLICATION

REASONABLE ACCOMMODATIONS