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Get a Free Disability Claim Consultation
Would you like more information about your legal options? We'll get back to you quickly for a consultation concerning your case.
Step 1 of 5 - About You
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Your name
*
First
Last
Your date of birth
DD
MM
YYYY
Street Address
City
*
Province
*
New Brunswick
Nova Scotia
Prince Edward Island
Postal Code
Phone
*
Email
Preferred Contact Method
Phone
Email
Who was your employer when you were taken off work?
*
Employer's Address
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Your job title
How long you worked there
Are you in a union?
*
Yes, I am in a union
No, I am not in a union
Name of your disability insurance company
*
Name of your insurance representative
First
Last
Insurance policy number
Claim or ID number
Do you have a copy of your employee benefits information?
Yes, I have a copy
No, I don't have a copy
What is the medical condition, illness or injury that is preventing you from working?
*
When were you first diagnosed with this condition?
*
When did you first notice symptoms from this condition?
*
What is the last day you worked?
*
DD
MM
YYYY
In your own words, why can't you return to your job?
*
Are you likely to get better, or is your condition or disability permanent?
*
I am likely to get better
My disability is permanent
Did you miss time from work in the past because of this same medical condition?
*
Yes, I missed time from work
No, I did not miss time from work
Please explain how and why you missed time from work:
*
Did you file an application for disability benefits?
*
Yes, I filed an application
No, I did not file an application
When did you sign the documents?
DD
MM
YYYY
Did the insurer approve your application for disability benefits?
*
Yes, my application was approved
No, my application was not approved
On which date were the benefits approved?
DD
MM
YYYY
Did you receive any monthly benefit payments?
*
Yes, I received benefit payments
No, I did not receive benefit payments
Did the insurer stop payment of monthly benefits?
*
Yes, the insurer stopped my payments
No, the insurer did not stop my payments
On which date did the payments stop?
DD
MM
YYYY
What is the monthly payment ($) you believe you are entitled to?
Did you receive a letter from the insurer saying your claim was denied or discontinued?
*
Yes
No
Have you applied for CPP disability benefits?
*
Yes, I applied for CPP benefits
No, I did not apply for CPP benefits
What is the status of your CPP disability benefits application?
*
Approved
Denied
Pending
Comments
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Cantini Law Group
Personal Injury Lawyers since 1987 | Moncton, Halifax & Charlottetown
