29610 Southfield Road | Southfield, MI 48076
(248) 559-7170 | (800) 336-4322 | FAX (248) 559-7466
disabilitybenefitscorporation@gmail.com

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Name
Address
City
State
Zip
Phone	Ext
Soc. Sec. #
Date of Birth
Date Last Worked

Company Name
Address
City
State
Zip
Phone	Ext
Contact
File #
Policy #

Disability/Diagnosis

Physician(s)

Work History item one item two item three item four

Employer

Job Title or Main Occupation

Education

Social Security Claim Status (if applicable)

Disability Insurance Company (Current and Pending)

Type item one item two item three item four item five item six item seven

• If 'Type' is amount enter amount

Comments/Remarks

Services Requested

Evaluation & Recommendations
Claim Representation