QuestionaireGreyBox


Home » Client Questionnaire
Print this PageSend to a Friend

Client Questionnaire

Review this website and its resource links to determine what type of claim you may have and fill out the intake form for a free claim review.

The clients for whom I can provide effective counsel are:

  • Employees and individuals who have been denied disability and pension benefits.
  • Employees and individuals who have been denied continued health coverage during periods of family caregiving or following termination of employment.
  • Partners, managers, administrators, and others who need to negotiate executive compensation or severance arrangements, or reasonable exit and non-competition agreements.
  • Former employees who are sued over unreasonable non-competition or “non-compete” agreements.
  • Employees and individuals who have been discriminated against. 
  • Reasonable people who have serious problems in the workplace.
  • Whistleblowers (Sarbanes-Oxley, health & safety, and others).
* = Required Field
Name* Home Telephone Number* Mobile Phone Number
Fax Number Email Address* Date of Birth
Social Security Number marital-status Status Employer or Former Employer
Name of Insurance Company or Benefit Plan*
from which you are seeking benefits
What type of legal problem(s) do you have?*
Lost Pension or pension benefit too low
Lost health & welfare benefit ot health & welfare too low
Did not get a severance benefit
Long-term disability insurance claim
Workers' Compensation claim
Social Security Claim
Discrimination on the job
(specify type, if other explain)
Please Describe what happened and why you think you have a claim*
If you have difficulty explaining and you have a letter or other document you think will help us, please send a copy to us
Have you filed an application for benefits?*
If so, when?
Did you recieve a response to the application?
If so, what was the date of the response?
Was your claim denied or terminated?
Does the denial/termination letter state that you may appeal?
Did you file an appeal?
If so, when?
(Specify the date you filed your appeal)
Did you recieve a response to the appeal?
If so, when?
(Specify the date you recieve a response to your appeal)
If you did not get a response, when is the appeal due?
(Specify the date your appeal is due)
If this is a pension claim, are you seeking a lump sum amount?
If so, what is the amount?
For Disability Claims
Briefly describe your disability
(list all medical conditions involved)
Are you currently recieving Social Security benefits?
If not, have you applied before?
If you currently recieve or previously recieved Social Security benefits, what is/was the monthly amount?
Are you recieving Workers' Compensation?
If yes, what is the monthly amount?
If no, have you applied for Workers' Compensation?
What is the status of your Workers' Compensation claim?
What was your annual salary from your last employer?
If you previously recieved long-term disability benefits, what is/was the gross monthly amount?
Breifly describe your work experience for the past 15 years, beginning with the most recent.
Do you anticipate returning to your previous job or any other occupation in the near futre?
If yes, when and to what position?
If no, why?
Are you participating in any vocational rehabilitation or educational program?
If yes, please list the name of the program, your proposed goal and the name and address of your counselor, if any.
Please read the following carefully.

I am submitting this questionnaire and attachments for review by the Law Office of Denise M. Clark, PLLC. I understand the following:

  1. That the submission of information is for review only and that there will be no charge for this review.
  2. Law Office of Denise M. Clark, PLLC and I have not entered into an attorney-client relationship and are not acting as my attorney unless and until a formal, written Retainer Agreement has been signed both by me and by a representative of Law Office of Denise M. Clark, PLLC. No decision has yet been made on whether Law Office of Denise M. Clark, PLLC will take my case and there is no guarantee that the firm will accept my case.
  3. Further information may be requested in order for Law Office of Denise M. Clark, PLLC to reach a decision.
  4. 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.