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Chris Collett
2019-05-01T22:55:15+00:00
1
Claims Manager Information
2
Claimant Information
3
Case Information
First Name
*
Last Name
*
Claim Admin's Email
*
Title
*
Company
*
Claim Number
*
Policy Number
*
First Name
Last Name
Date of Birth
*
Date Format: MM slash DD slash YYYY
Occupation
Date Last Worked
*
Date Format: MM slash DD slash YYYY
Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Impairment
*
Current SSDI Application Pending?
*
Yes
No
Current Status:
Initial Claim
Reconsideration
Hearing Level
Appeals Council
Previously Denied SSDI?
*
Yes
No
Level of Last Denial:
Initial Claim
Reconsideration
Hearing Level
Appeals Council
Date of Last SSDI Denial
Date Format: MM slash DD slash YYYY
LTD: Date of Change in Definition
Date Format: MM slash DD slash YYYY
LTD: Date of Termination
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
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