Name
Address
City
State
Zip
Phone
Cell Phone
Email
Date of Birth
Social Security No.
Employer
Insurance Company
Please describe what happened and why you think you have a claim.
2a. Have you filed an application for benefits?	Yes No
2b. If so, when?
2c. Did you receive a response to the application?	Yes No
2d. If so, what was the date of the response?
3. Was your claim denied or terminated?	Yes No
4a. Did you file an appeal?	Yes No
4b. Did you get a response?	Yes No
4c. If so, what was the date of the response?
FOR DISABILITY CLAIMS
A. Please describe your disability(list all medical conditions involved).
B1. Are you currently receiving Social Security benefits?	Yes No
B2. If not, have you applied before?	Yes No
B3. If you currently receive Social Security benefits, what is the amount?
C1. Are you receiving Worker's Compensation benefits?	Yes No
C2. If so, what is the monthly amount?
D. If you receive or previously received long-term disability benefits, what is/was the gross monthly amount?
PLEASE READ CAREFULLY
I am submitting this questionnaire and attachments for review by the O'Ryan Law Firm. I understand the following:
1. The O'Ryan Law Firm and I have not entered into any attorney-client relationship and are not acting as my attorney unless and until a formal, written Contract for Services has been signed by both me and a representative of the  O'Ryan Law Firm. No decision has yet been made on whether the  O'Ryan Law Firm will take my case and there is no guarantee that the firm will accept my case. 2. It takes time to review the material submitted and to make any reply or decision. Because no attorney-client relationship has yet been established, I will be responsible until I am notified otherwise to meet all necessary deadlines and time frames applicable to my claim; and I acknowledge that I have not received any representations or legal opinions with respect to any time frames or deadlines that may be applicable to my claim.
I have read and agree to all of the above conditions. (please check the box)
Copyright© 2006 O'Ryan Law Firm. All Rights Reserved.