Krafchick.com

Thank you for filling out this questionnaire. In order to determine if we can be of service to you, it will be useful for you to answer a few specific questions.

1.	Name:
2.	Address:
3.	Phone Number:
4.	Email Address:
5.	Social Security Number:
6.	Birth Date:
7.	What physical or mental conditions keep you from working?
8.	Who is your employer?
9.	How much is the monthly benefit at issue?
10.	What is the date of the last day you worked?
11.	What was your job? (Title and job description.)
12.	Have you applied for SSD (Social Security Disability)? If so, have you been awarded SSD? What is the monthly SSD payment that you receive?
13.	Do you know whether or not your claim is covered by ERISA?
14.	Would you be willing to travel to Seattle to be evaluated by experts that we may want to refer you to?	Yes No
15.	Are you able to pay any money towards the costs of preparing your case? (The costs may run between $5,000 - $7,000 for expert evaluations.)
16.	Please add any information that you feel is pertinent to your claim.
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