9800 Centre Parkway, Suite 150 • Houston, Texas 77036 • Phone: 713-266-1380 • Fax: 713-266-2432 Email: michael@hengstandhenderson.com
Submit A Claim I have a claim for: Social Security Long-Term Disability *Your Name: Date of Birth: Age: Home Address: City: State: Zip Code: County: Telephone: *E-Mail Address: Dress yourself without help: Y or N Housecleaning chores without help: Y or N Describe medical problems: Describe disabilities: Name of Company: Name of Disability Provider under the Company Plan: When did you first apply for Disability? What is the date of the last decision regarding your disability? Is your denial for benefits final? Please state the highest grade you completed in school. What was the last day you worked: (day, month, year) What type of work were you doing? Are you currently receiving social security disability benefits? Have you ever applied for Social Security Disability before? Have you ever received Social Security Disability before? *Required Fields Copyright 2003 by Hengst & Henderson. All rights reserved.
I have a claim for: Social Security Long-Term Disability
*Your Name:
Date of Birth:
Age:
Home Address:
City:
State:
Zip Code:
County:
Telephone:
*E-Mail Address:
Dress yourself without help: Y or N
Housecleaning chores without help: Y or N
Describe medical problems:
Describe disabilities:
Name of Company:
Name of Disability Provider under the Company Plan:
When did you first apply for Disability?
What is the date of the last decision regarding your disability?
Is your denial for benefits final?
Please state the highest grade you completed in school.
What was the last day you worked: (day, month, year)
What type of work were you doing?
Are you currently receiving social security disability benefits?
Have you ever applied for Social Security Disability before?
Have you ever received Social Security Disability before?
*Required Fields
Copyright 2003 by Hengst & Henderson. All rights reserved.
