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Learn
About
Practice Areas
Contact us
☏ (973)908-8638
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I. CONTACT INFORMATION
Name
*
First Name
Last Name
Your mailing address
Email Address
*
Telephone / Cell Phone
(###)
###
####
Your Social Security Number
Date of Birth
MM
DD
YYYY
II. EMPLOYMENT INFORMATION
Your occupation
Location (city & state) where you work(ed)
Are you currently working for this employer?
If not, what was your last day at work?
During your last full year of employment, what was your income from this employer?
Name of your employer / former employer
Approximately how many people work for this employer?
How many years of service did you have with this employer (including corporate predecessors)?
Have you or your spouse ever been involved as a plaintiff or a defendant in any lawsuit?
YES
NO
If the answer is ‘yes,’ please state the case caption and where the lawsuit was filed. For example, John Doe v. Jane Smith, New Jersey State Court:
Is your employer / former employer a government? In other words, were you / are you employed by the federal government, state, county, city, township, municipality, state college / university, or a political subdivision?
If the answer is “Yes,” please proceed to Section III A. If the answer is “No,” please proceed to Section III B.
YES
NO
III. FRINGE-BENEFITS PLAN AT ISSUE
A. Government employees if the fringe-benefits plan at issue is . . . . . . then jump to Section . . . Teachers Pension & Annuity Fund (“TPAF”) IV Police & Firefighters Retirement System (“PFRS”) IV Public Employees Retirement System (“PERS”) IV State Employees Health Plan ("SEHP") or School Employees Health Benefit Plan ("SEHBP") X Judicial Retirement System (“JRS”) IV State Police Retirement System (“SPRS”) IV Other than New Jersey XI B. Non-governmental employees if the fringe-benefits plan at issue is . . . . . . then jump to Section . . . Health Insurance / Medical Benefits V Short Term Disability / Long Term Disability VI Pension / 401(k) VII Through your Labor Union VIII Executive Compensation IX Airline Travel Privileges XII Sick Pay Plan XIII Life Insurance XIV Long Term Care Insurance XV
IV. GOVERNMENT EMPLOYEES
A. Indicate your pension fund
TPAF Teachers Pension & Annuity Fund
PERS Public Employees Retirement System
PFRS Police & Firemen Retirement System
JRS Judicial Retirement System
SPRS State Police Retirement System
B. What’s your Member Number?
C. Do you have access to MBOS?
YES
NO
D. Upon request, are you willing to provide to the attorney the username and password to your MBOS account?
YES
NO
E. Have you received from the Division of Pensions & Benefits a notice regarding any of the following (check where appropriate):
Honorable Service Yes
Honorable Service No
Non-Bona Fide Retirement Yes
Non-Bona Fide Retirement No
Denial of Benefits Yes
Denial of Benefits No
Purchase of Service Credit Yes
Purchase of Service Credit No
F. Are you interesting in applying for Disability Retirement?
YES
NO
G. CLIENT ACTION:
If the answer to Question IV. F. is “No,” please just to Question P. If the answer to Question IV. F. is “Yes,” please move to the next line (“H”). H. Access the Internet. I. Point your browser to www.Google.com J. Within the Google search box, enter the name of the fund you indicated in response to Question IV. A. K. Select the search result which most closely corresponds to “Member Handbook” or “Plan Rules.” Open up the PDF document on your computer. L. Within your browser, search for the phrase “several types of retirement” (without quotes). M. Utilize the protocol set out in that document to determine your monthly entitlement to Disability Retirement. Note that the monthly rate for Disability Retirement is different between Ordinary and Accidental.
N. State here what you would receive every month in Disability Retirement (if the application were approved): ($)
O. CLIENT ACTION: Please proceed now to Section VI and complete subsections B & C.
P. In the space provided and in a few sentences, please describe in your own words what your pension case is all about:
V. HEALTH INSURANCE / MEDICAL BENEFITS
A. If your health benefits plan is fully-insured, state the name of the Carrier:
B. How many medical claims are outstanding?
1 to 3
3 to 10
10 to 25
> 50
C. In the aggregate, what is the dollar amount of the outstanding medical claims?
0 to $50,000
$50,000 to $200,000
$200,000 to $500,000
> $500,000
With respect to the medical creditors who have the largest outstanding claims, has the billing staff provided assistance as you try to secure reimbursement from the group health plan?
YES
NO
In the space provided, please describe in your own words what your medical benefits case is all about:
Are you receiving Social Security Disability benefits?
YES
NO
If “Yes,” how much every month? ($)
If “Yes,” as of what date did the monthly Social Security Disability start?
MM
DD
YYYY
Have you submitted a written request for documentation?
YES
NO
Are you taking prescription medications for your condition(s)? If so, please list each such mediation, the dosage, for what conditions / symptoms you’re taking it, and any side-effects you’re experiencing.
In the space provided, please describe in your own words what your disability case is all about:
VII. PENSION / 401(k)
What kind of pension do you participate in?
Profit-Sharing Plan
401(k)
Money Purchase Plan
Traditional Defined-benefit Pension
Supplemental Executive Retirement Plan (“SERP”) -if you participate in a SERP, jump to Section IX
Have you submitted a Claim for Benefits?
YES
NO
Have you submitted an Appeal of a Denied Claim?
YES
NO
When did you first have any inkling that a problem existed with your pension account?
After you figured out that there may be a problem with your pension, when did you first decide that you needed to speak with a lawyer?
Please provide an inventory of the documents you have in your possession regarding your issue:
Will be asked through Email
Has your pension plan claimed that you were overpaid?
YES
NO
If the answer is Question VII. G. is “Yes,” how much is the overpayment?($)
In the space provided, and in the most general way possible, explain your issue relating to pension benefits:
VIII. UNION-RELATED FRINGE BENEFITS
What union local are you in?
What city and state is that local in?
What International covers that local? (eg: Teamsters, Carpenters, Autoworkers, Machinists, etc.)
How many years have you been associated with that union local?
In the space provided, and in the most general way possible, explain your issue with union-related fringe benefits:
If your issue with respect to the Labor Union involves a pension, please jump now to Section VII.
IX. EXECUTIVE COMPENSATION
Are you a participant in any of the following types of plans (check as applicable):
Stock Option Plan
Stock Ownership Plan
Long Term Incentive Plan
Restricted Stock Units
Profit Sharing
Bonus Awards Program
Supplemental Executive Retirement Plan (“SERP”)
Other
Within the past seven tax years, have you received a notice from your employer that your income has exceeded the cap specified at Internal Revenue Code § 401(a)(17) ?
YES
NO
If your response to IX. B. is “Yes,” is your employer providing non-qualified deferred compensation for earnings in excess of $275,000 (tax year 2018) ?
YES
NO
For each of the plans you selected in response to Section IX. A., above, provide an inventory of the “rules-and-regs” documentation you have in your possession (e.g.: prospectus, Summary Plan Description, offer letter, etc.):
: In the space provided, explain your situation with Executive Compensation (i.e., why are you seeking out counsel? ):
X. STATE EMPLOYEES HEALTH PLAN or SCHOOL EMPLOYEES HEALTH BENEFITS PLAN
A. Has your medical-benefits case been heard by the Division of Pensions & Benefits in Trenton?
YES
NO
B. Did the Division of Pensions & Benefits provide any relief, even if just for a portion of the medical claims?
YES
NO
C. If the Division of Pension & Benefits did not provide all the relief requested with respect to your medical benefits claim, indicate how much was approved and how much was not approved?
Approved
Not Approved
D. Has your medical-benefits case been heard by the Board of Trustees?
YES
NO
In the space provided and in your own words, please describe your health insurance case:
Please proceed to Section V of this Intake Sheet and follow the instructions.
XI. BENEFITS AVAILABLE TO GOVERNMENT EMPLOYEES – NOT DISCUSSED ABOVE
If you are presently or formerly employed by a governmental agency but not in New Jersey, please briefly describe your situation:
What state are you employed in?
What is the name of that state’s retirement system in which you participate?
XII. AIRLINE TRAVEL PRIVILEGES
Have you filed a Claim for Travel Privileges?
YES
NO
Was the Claim Denied?
YES
NO
If “Yes,” what is the date of the Claim Denial?
MM
DD
YYYY
In the space provided and in three or four sentences, please describe in your own words why the Airline denied your Claim:
What is the date of your Claim?
MM
DD
YYYY
Have you filed an Appeal of a Denied Claim?
YES
NO
Was the Appeal denied?
YES
NO
If “Yes,” what is the date of the Appeal Denial?
MM
DD
YYYY
In the space provided and in three or four sentences, please describe in your own words why the Airline denied your Appeal:
XIII. SICK PAY BENEFITS
Have you filed a Claim?
YES
NO
Was the Claim Denied?
YES
NO
If “Yes,” what is the date of the Claim Denial?
MM
DD
YYYY
In the space provided and in three or four sentences, please describe in your own words why your Claim was denied:
What is the date of your Claim?
MM
DD
YYYY
Have you filed an Appeal of a Denied Claim?
YES
NO
Was the Appeal denied?
YES
NO
If “Yes,” what is the date of the Appeal Denial?
MM
DD
YYYY
In the space provided and in three or four sentences, please describe in your own words why your Appeal was denied:
How many Sick Days are at stake here?
What is the approximate dollar value of the total number of Sick Days?
XIV. LIFE INSURANCE
Have you filed a Claim?
YES
NO
Was the Claim Denied?
YES
NO
If “Yes,” what is the date of the Claim Denial?
MM
DD
YYYY
In the space provided and in three or four sentences, please describe in your own words why your Claim was denied:
What is the date of your Claim?
MM
DD
YYYY
Have you filed an Appeal of a Denied Claim?
YES
NO
Was the Appeal denied?
YES
NO
If “Yes,” what is the date of the Appeal Denial?
MM
DD
YYYY
In the space provided and in three or four sentences, please describe in your own words why your Appeal was denied:
Insurance carrier underwriting this policy:
XV. LONG TERM CARE INSURANCE
Have you filed a Claim?
YES
NO
Was the Claim Denied?
YES
NO
If “Yes,” what is the date of the Claim Denial?
MM
DD
YYYY
In the space provided and in three or four sentences, please describe in your own words why your Claim was denied:
What is the date of your Claim?
MM
DD
YYYY
Have you filed an Appeal of a Denied Claim?
YES
NO
Was the Appeal denied?
YES
NO
If “Yes,” what is the date of the Appeal Denial?
MM
DD
YYYY
In the space provided and in three or four sentences, please describe in your own words why your Appeal was denied:
Insurance carrier underwriting this policy:
Thank you!
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