1. *INSURED FIRST \\ 
2. *INSURED LAST \\ 
3. *INSURED ADD1 \\ 
4. *INSURED ADD2 \\ 
5. *INSURED CITY \\ 
6. *INSURED STATE \\ 
7. *INSURED ZIP \\ 
8. *INSURED PHONE \\ 
9. *INSURED E-MAIL \\ 
10. *INSURED FAX \\ 
11. *OCCUPATION \\ 
12. *ATTORNEY FIRST \\ 
13. *ATTORNEY LAST \\ 
14. *ATTORNEY ADD1 \\ 
15. *ATTORNEY ADD2 \\ 
16. *ATTORNEY CITY \\ 
17. *ATTORNEY STATE \\ 
18. *ATTORNEY ZIP \\ 
19. *ATTY PHONE \\ 
20. *ATTY E-MAIL \\ 
21. *ATTY FAX \\ 
22. *IS ATTORNEY 1 WILLING TO TAKE NEW CASES? \\ 
23. *ATTORNEY 2 FIRST \\ 
24. *ATTORNEY 2 LAST \\ 
25. *ATTORNEY 2 ADD1 \\ 
26. *ATTORNEY 2 ADD2 \\ 
27. *ATTORNEY 2 ADD3 \\ 
28. *ATTORNEY 2 CITY \\ 
29. *ATTORNEY 2 STATE \\ 
30. *ATTORNEY 2 ZIP \\ 
31. *ATTORNEY 2 PHONE \\ 
32. *ATTORNEY 2 E-MAIL \\ 
33. *ATTORNEY 2 FAX \\ 
34. *IS ATTORNEY 2 WILLING TO TAKE NEW CASES? \\ 
35. *LIST OF REPORTED DECISIONS \\ 
36. *AGE AT TIME OF DISABILITY \\ 
37. *DATE OF CLAIM \\ 
38. *NAME OF UNUM ATTYS \\ 
39. *FIRM NAME OF UNUM ATTY \\ 
40. *INVASION OF PRIVACY BY P/I? \\ 
41. *FRAUD BY PI? \\ 
42. *IME FRAUD ISSUE? \\ 
43. *MISREP ON DR. REPORT ISSUE? \\ 
44. *WAS UNUM ADJUDICATED TO HAVE VIOLATED ANY LAW? \\ 
45. *WAS THERE COLA RIDER? \\ 
46. *WHERE PMNTS EVER MADE? \\ 
47. *FIRST PMNT MADE \\ 
48. *LAST PMNT MADE \\ 
49. *EEOC RIGHT TO SUE LETTER SOUGHT? \\ 
50. *ERISA? \\ 
51. *DID FORMER EMPLOYER ASSIST IN CLAIM? \\ 
52. *DID FORMER EMPLOYER INTERFERE WITH CLAIM? \\ 
53. *STATE CLAIM? \\ 
54. *ON MORRIS \\ 
55. *ON 1,044? \\ 
56. *ON 2,152? \\ 
57. *ON UNUM TROUBLE LIST? \\ 
58. *HAS CLIENT FILED BNCY? \\ 
59. *SOLD THEIR HOME? \\ 
60. *ATTEMPTED SUICIDE? \\ 
61. *DIED PENDING LIT? \\ 
62. *CAUSE OF DEATH \\ 
63. *SOURCE OF FUNDS FOR LIVING EXPENSES? \\ 
64. *ORIG SETTLEMENT OFFER AS % OF POLICY \\ 
65. *FINAL SETTLMENT OFFER AS % OF POLICY \\ 
66. *PERCENTAGE DIFFERENCE ORIG TO FINAL \\ 
67. *COMPLAINT TO DPT OF INS? \\ 
68. *COMPLAINT TO AG? \\ 
69. *COMPLAINT \\ 
70. *STATE FILING DATE \\ 
71. *FEDERAL FILING DATE \\ 
72. *JURISDICTION \\ 
73. *VENUE \\ 
74. *DOCKET NUMBER \\ 
75. *CLAIM BY INSURER? \\ 
76. *SETTLED? \\ 
77. *WAS SETTLEMENT NET OR GROSS? \\ 
78. *DATE SETTLED \\ 
79. *CONFIDENTIAL \\ 
80. *DID UNUM FILE MSJ? \\ 
81. *DID INSURED FILE MSJ? \\ 
82. *RESULT OF MSJ? \\ 
83. *TRIAL TO VERDICT? \\ 
84. *RESULT OF TRIAL \\ 
85. *SSD DISABLED? \\ 
86. *MONTHLY BENEFIT \\ $
87. *DATE OF LAST UPDATE \\ 
88. *DIAGNOSIS \\ 
89. *BASIS FOR DENIAL \\ 
90. *UNUM \\ 
91. *Provident/Paul Revere \\ 
92. *Standard \\ 
93. *Cigna \\ 
94. *CNA \\ 
95. *Other \\ 
96. *BLANKET CONSENT FORM REQUESTED \\
97  *BLANKET CONSENT FORM SIGNED BY YOU \\
98  *CREDIT REPORTS DONE DURING CLAIMS PROCESSING? \\
99  *OTHER \\
100 *NARRATIVE \\