Sample claim file request

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 236-238

Form 8 ERISA Disability Claims and Litigation A-218

FORM 8 SAMPLE CLAIM FILE REQUEST

Date

VIA FAX & MAIL

INSURER

ADDRESS

FAX

Re: CLIENT

DOB:

Claim No.:

Dear NAME:

We represent CLIENT in connection with his claim for Long Term Disability



our representation and allow for communications/ the release of all documentation



Please be advised that CLIENT intends to seek review of the adverse determi-

nation from INSURER. However, before CLIENT can adequately present his case

and obtain a full and fair review, CLIENT must have an opportunity to review the

documents relied upon by INSURER in denying his claim. Accordingly, pursuant

to Section 104(b) of ERISA and 29 C.F.R. 2560.503-1(h)(2)(iii), we hereby request

copies of the following documents (in order to save paper please send all requested

documents in the form of an Adobe PDF):

1) A copy of all documents constituting the Plan, including: (i) the Policy

and any riders or schedules thereto; and (ii) the contract for long term

disability coverage between you and CLIENT’s employer;

2) A copy of the summary plan description of the plan;

3) All documents:

   

limitation, all reports, notes, records, test results, correspondence

and curriculum vitae of any independent medical examiner/reviewer,

functional capacity evaluator, transferable skills expert, and/or voca-

tional expert. See 29 C.F.R. 2560.503-1(h)(2)(iii) and 29 C.F.R.

2560.503-1(m)(8)(i);