1.  Do not delete any numbers or headings.  All fields must be in place
or it will screw things up.  (Don't worry we'll check them before we
input them into the database just in case someone decides to get funny.)
2.  If you don't know the answer to a field or it is not
applicable - simply write "Don't know" or "not applicable"
as your answer beside the Heading.
more room, put an asterisk [*] and the question number [i.e. *31] and then continue your answer in the narrative section at the end of the questionnaire.  Example: In narrative section write *31 and finish
your answer.
4.  I am using the word UNUM in a generic sense to refer to YOUR INSURANCE COMPANY.  IF your insurer IS NOT UNUM, you will be able to tell us in the section at the bottom of the page, questions 90-95.  The computer program will then sort out the answers into UNUM, Provident, Metlife, Cigna, Standard, etc.
5.  Remember your insurance company already probably knows the answers to ALL of these questions ABOUT YOU.  Please help us by giving us the information.  It is next to impossible to get the insurers to give us the statistics we need to confirm our suspicions.  The Court battles can last for years.
6.  Please do not get bogged down in details.  If you do not understand the
question, your answer should be "Don't understand the question."  We will get
back to you when we have time.  Please do not call me or Sam about this.  We will be very busy.
7.  WE NEED REAL NAMES AND REAL INFORMATION.  If you won't provide your name
and identifying information, please don't waste our time.
8.  We are not asking for any information that your insurance company doesn't
already know about you. If you tell the truth, you should not have any problem with this information being "used against you."
9.  Being able to fill out this form does not constitute the ability to
reliably perform the job requirements of any job that I know of.  Most of you
will not be able to complete these forms in one sitting.

Remember, if you can fill out those annoying forms from your insurance company, Social Security, etc., you can surely manage to do this.  If you

Question 1:  INSURED FIRST - Your first name.  If you customarily use a middle initial or middle name, you can put that in this field too.

Question 2:  INSURED LAST - Your last name.

Question 3:  INSURED ADD1 - Your house number and street address

Question 4:  INSURED ADD2 - P.O. Box/Apartment number/etc.  If you only need
the first address line, then you can write "N/A" for not applicable, or leave it blank - but don't delete it.

Question 5:  INSURED CITY - Your city or town

Question 6:  INSURED STATE - Your state

Question 7:  INSURED ZIP - Your zip code (5 and/or 9 numbers)

Question 8:  INSURED PHONE - Your phone number including area code - please don't play games by leaving this blank, we need a way to get a hold of you if there is a question or something that needs to be clarified in your answers.  We won't give your number out to telephone solicitors.

Question 9:  INSURED FAX - If you have one.  If not, leave it BLANK or put
NONE.  Do not delete the question.

Question 10:  INSURED E-MAIL - If you are getting this questionnaire from a 
non-computer source, it will be most helpful if you could find someone,
a friend or relative, who can RECEIVE e-mail messages for you so we can
send you updates on our progress.

Question 11:  OCCUPATION - We want to know the last occupation you had, i.e.
the occupation you are disabled from.  For example, I was an Emergency Room

Question 12:  ATTORNEY FIRST - Your attorney's first name.  If you don't have
an attorney, you can write N/A or leave it blank.  If you have tried to find
an attorney without success, please write "Tried to find one but couldn't"
You can elaborate on your attempts to find legal representation in the Narrative Section at the end of this questionnaire.

Question 13:  ATTORNEY LAST - Your attorney's last name.

Question 14:  ATTORNEY ADD1 - Your attorney's street address

Question 15:  ATTORNEY ADD2 - Additional address information or leave blank
P.O. Boxes, Suite Number, etc.

Question 16:  ATTORNEY CITY - Your attorney's city

Question 17:  ATTORNEY STATE - Your attorney's state

Question 18:  ATTORNEY ZIP - Your attorney's zip code

Question 19:  ATTORNEY PHONE - Your attorney's telephone number including area code

Question 20:  ATTORNEY E-MAIL - Your attorney's e-mail address.  If your
attorney does not have an e-mail address, I would strongly suggest that
you tell him to get one.  Remember, you can leave the space blank but do
not delete the question.

Question 21:  ATTORNEY FAX - Your attorney's fax number

Question 22:  IS ATTORNEY 1 WILLING TO TAKE NEW CASES?  A yes or no answer
will do.

If you have a second attorney on your case, use the same instructions to fill
out questions 23 through 34
 - - - - - - - - - - - - - -  TAKE A BREATHER - - - - - - - - - - - - 

Question 35:  LIST OF REPORTED DECISIONS - This field asks whether there is any published decision or opinion about your case.  Your attorney should know
this.  If there is a published decision, it would be helpful if gave the
citation number or send us a copy.

Question 36:  AGE AT TIME OF DISABILITY - This will be how old you were when you first made your claim for benefits.

Question 37:  DATE OF CLAIM - This could be the date you put on your initial
application for benefits, or if for some reason, you were one of those people
that didn't submit a claim for a long time, put the date you last worked at 
your job, and elaborate in the narrative section on why you didn't file your claim (i.e. your employer didn't tell you that you were eligible for benefits, etc.)

Question 38:  NAME OF UNUM ATTORNEYS - If you know, you can list both in-house and outside counsel.  If you aren't litigating, you can leave it blank,
write N/A, etc. but don't delete the question.

Question 39:  FIRM NAME OF UNUM ATTORNEY - Self-explanatory

here for people who have been harassed, if someone has talked to your neighbors and you have found out that they lied to your neighbors about you,
if they were on your property, etc.  If you don't know if you have been
followed by PI's, you can write "Don't know."  If you have a good story
of harassment, just write "YES *40, was harassed."  Then go down to the
Narrative section at the end and give us the details.  Also in the Narrative
the name of the Investigation agencies and their locations if you or your
lawyer know.

Question 41:  FRAUD BY PRIVATE INVESTIGATORS? - This field asks whether the
Private Investigator(s) wrote a report which was not supported by what was observed, or if the investigator engaged in conversation with the claimant
and misrepresented what was said in his/her report, tried to intimidate, or
made veiled threats of problems that might occur.  If you had a "home visit"
and this occurred, you can answer that here.  Remember just a short answer
in the blank next to the question and then elaborate in the Narrative
section below with a *41 to show which question you are referring to.

Question 42:  IME FRAUD ISSUE? - This field asks whether an "Independent Medical Examination" resulted in a report in which UNUM coerces the examining
doctor and told them what to say or tried to get them to change a report that was favorable to you to an unfavorable report.  Put your details in the 
Narrative section.  If no IME was ever done - please write "No IME ever done."

Question 43:  MISREP on DR. REPORT ISSUE? - If you had a totally fraudulent
IME (8 minute exam resulting in an 8 page report calling you a malingerer, etc.).  Write yes or no, then elaborate in Narrative section.  If you didn't
have an IME but had significant misrepresentations (as I did) of what your
OWN treating physicians said in phone conversations (what UNUM calls
"doc to doc") please relate those details in the narrative section.  Give names of any "doctors" or "nurses" that were involved in your case either
as UNUM doctor or IME doctor.

Question 44:  WAS UNUM ADJUDICATED TO HAVE VIOLATED ANY LAW? - This field asks whether UNUM was found guilty of violating an law or regulation.  The most common example is the use of a defective denial letter by UNUM in ERISA cases.  Elaborate in the narrative section.

Question 45:  WAS THERE COLA RIDER? - This field asks if there was a Cost of
Living rider purchased with your policy or included in an employer provided

Question 46:  WERE PMNTS EVER MADE? -   Were any payments ever made?  Yes or no.  In the case of a token insignificant payment (as in my case), please elaborate in the narrative section.

Question 47:  FIRST PMNT MADE - Date of first payment (month and/or year if
you can't remember the exact date)

Question 48:  LAST PAYMENT MADE - Date you received your last payment.  If you have been terminated, reinstated, terminated, etc., please elaborate in
the Narrative section below.

Question 49:  EEOC RIGHT TO SUE LETTER SOUGHT? - Did you file a complaint with the Equal Opportunity Employment Commission against your insurer?

Question 50:  ERISA - Most patients who have their insurance ONLY from their
employer will be classified as ERISA (Employee Retirement Income Security Act) claims.  Exceptions are government and religious groups.  If you bought
your own policy and paid your own premiums, and it was not part of any group policy it IS NOT ERISA.  If UNUM tried to misclassify your PRIVATE policy
as ERISA to drive up your litigation costs, please elaborate in the Narrative
section.  If you don't know, just answer "Don't know."

Question 51:  DID FORMER EMPLOYER ASSIST IN CLAIM? - When you started having difficulties with your insurer, did your former employer come to your aide and do anything significant to help you in getting your claim paid?  Or did they merely complicate the process and then insist that the problems was between you and the insurer?  Elaborate in Narrative section if necessary.

Question 52:  DID FORMER EMPLOYER INTERFERE WITH YOUR CLAIM? - Do you think your former employer interfered or made it more difficult for you to get a legitimate claim paid.  Elaborate in narrative section below.

Question 53:  STATE CLAIM - Was your lawsuit (if you filed a lawsuit) filed in a State Court at any time?  Please give details, docket number, name of Court.

Question 54:  ON MORRIS?  - Is Dr. Judy Morris aware of your situation?  Have you been in contact with her?  Are you on her Internet Coollist?

Question 55:  ON 1,044? - Leave this question blank.  This pertains to a list
of lawsuits UNUM had to produce.  Do not delete the question.  We will fill it in.

Question 56:  ON 2,152? - Leave this question blank. This pertains to another
list we have obtained.  Do not delete the question.  We will fill it in.

Question 57:  ON UNUM TROUBLE LIST? - Leave this question blank as well.

Question 58:  HAVE YOU (OR YOUR CLIENT) FILED BANKRUPTCY?  - Yes or No, date of filing?  Was it a result of insurer not paying properly?

Question 59:  SOLD THEIR HOME?  - Were you forced to sell a home or move to less expensive living situation as a direct result of your insurer not paying properly?

Question 60:  ATTEMPTED SUICIDE? - If you attempted suicide as a result of your insurer's actions, please state so here.  If you seriously considered suicide as a result of your insurer's actions, state so here?  Elaborate below if necessary.

Question 61:  DIED PENDING LITIGATION? - Did claimant die before claim was satisfactorily paid?

Question 62:  CAUSE OF DEATH?

Question 63:  SOURCE OF FUNDS FOR LIVING EXPENSES?  - Common choices - 
SSD, savings/retirement money, friends/relatives, loans, forced back to work, other (describe below if possible)

Question 64:  ORIG SETTLEMENT OFFER AS PERCENTAGE OF POLICY?  - Many people were offered a "lowball" settlement.  To get this figure, calculate the amount the insurer would have to pay if they honored your contract - i.e. for a permanent disabling condition with a policy that pays until age 65 you
would multiply you monthly benefit by how many months until your 65th
birthday.  Then take the amount offered and DIVIDE BY your total amount owed.  
Move the decimal 2 places to the right.  This does not have to be perfectly
accurate.  We don't need to calculate interest and Cost of Living.
For example:  I was 40 years old when I applied.  I am permanently disabled from my occupation as an ER doctor.  My two policies would have paid
approximately $12,000 per month until age 65.  That total is:
25 years X 12 months X $12,000 = $3,600,000.  UNUM offered me
approximately $80,000.  So my original settlement offer is:
$80,000 divided by $3,600,000 = .02.  Move the decimal two places to the
left for a grand total of 2%.

Question 65:  FINAL SETTLEMENT OFFER AS PERCENTAGE OF POLICY? - Most recent offer if your case is still pending?  After a year of litigation UNUM offered approximately 2 years worth of benefits for both of my policies (their "buyback" offer). Approximately $350,000.  $350,000 divided by approximately $3.5 million equals an astounding 10%!  We need ballpark figures only.

Question 66:  PERCENTAGE DIFFERENCE ORIGINAL TO FINAL? - obviously I'm not
through yet but we should get some interesting figures from those of you who settled.

Question 67:  COMPLAINT TO DEPARTMENT OF INSURANCE?  - Did you file a complaint with the Department of Insurance in your state?

Question 68:  COMPLAINT TO AG? - Did you file a complaint to your State
Attorney General?

Question 69:  COMPLAINT - Who else did you write to or ask for help?
(State reps/senators - give names, media, Department of Labor, Department
of Justice, FBI, Maine AG, Maine DOI, Board of Medicine,  etc.)  I complained to ALL of them numerous times.

- - - - - -Take a breather, and maybe a soothing cup of tea - - - - - - - - - 

Question 70:  STATE FILING DATE - Date lawsuit filed in State Court.  Write
"no lawsuit" if you didn't file a lawsuit.

Question 71:  FEDERAL FILING DATE - Date lawsuit filed in Federal Court
Write "no lawsuit" if you didn't file a lawsuit.

Question 72:  JURISDICTION - Your attorney can tell you, otherwise leave
blank.  Do not delete the question.

Question 73:  VENUE - Ask your attorney or leave blank.

Question 74:  DOCKET NUMBER - Docket number of lawsuit

Question 75:  CLAIM BY INSURER? - Yes/No.  Did your insurer sue or
threaten to sue or countersue you for benefits already paid?

Question 76:  SETTLED? - Yes/No

Question 77:  WAS SETTLEMENT NET OR GROSS? - How was your settlement
calculated?  Was it a percentage of "present-day" value or some other

Question 78:  DATE SETTLED - Self explanatory

Question 79:  CONFIDENTIAL - Is there a confidentiality agreement of any
kind.  If you are not prohibited from discussing the terms of the agreement
please elaborate in the Narrative section below.  In some cases you are
only prohibited from giving the amount of the settlement.

Question 80:  DID UNUM FILE MSJ? - Did UNUM file a Motion for Summary Judgment?

Question 81:  DID INSURED FILE MSJ? - Did claimant file a Motion for 
Summary Judgment?

Question 82:  RESULT OF MSJ?  - Result of the Motion for Summary judgment
(usually granted or denied)

Question 83:  TRIAL TO VERDICT?  - Was there a trial?  Before a judge?
Before a jury?

Question 84:  RESULT OF TRIAL? - Use Narrative section if necessary.

Question 85:  SSD DISABLED?  - Have you been determined to be disabled
by SSD?

Question 86:  MONTHLY BENEFIT - $ per month per policy

Question 87:  DATE OF LAST UPDATE - This field asks the most recent date of
information on this form.

Question 88:  DIAGNOSIS - YOUR doctor's diagnosis of you, NOT YOUR INSURER's.

Question 89:  BASIS FOR DENIAL - Choices are usually "Not disabled according
to the insurer,"  "Illness is mental not physical according to the insurer,"
"pre-existing condition," etc.

Question 90:  UNUM - Is your company UNUM? YES/NO

Question 91:  Provident/Paul Revere - Is your company Provident/Paul Revere?

Question 92:  STANDARD - Is your company Standard Insurance?  YES/NO

Question 93:  CIGNA - YES/NO

Question 94:  CNA - YES/NO

Question 95:  Other:  If you have National Life of Vermont, Indianapolis Life
or some other company that is having claims managed by UNUMPROVIDENT, put the
name of the company here but also state YES to UNUM or Provident.  If you 
have Metlife or some other company, you can write that in here.

Question 96: BLANKET CONSENT FORM REQUESTED - Were you asked to sign a 
blanket consent form as a condition for your claim being processed?

Question 97  BLANKET CONSENT FORM SIGNED BY YOU - Did you sign the form or
cross out parts of it?  Did you have trouble because you refused to sign
the form?  Elaborate in Narrative section

Question 98  CREDIT REPORTS DONE DURING CLAIMS PROCESSING?  - Were there credit reports in your claims file that were obtained AFTER YOU filed your
claim - This is a violation of a Federal Law, even if you consented.

Question 99  OTHER - I left this blank in case I think of anything else

Question 100 NARRATIVE  -  You might want to submit your narrative on a separate sheet of paper.  Make it as long or as short as you wish.   If you have special circumstances you wish to comment on, do it here.  If you had problems with your attorneys, please elaborate here.  Most of you probably
have some kind of description of your case already written up somewhere.  You
can use that here if you want.

OK, that's it for this form.  If we get the 50 cases I'm hoping for within
the first 30 days, we should have some preliminary results for you within a
month or two.  If you don't cooperate, it's going to be a lot harder (and
a lot more expensive) for ALL OF US.  In the near future I'll be sending
sample short blank affidavits forms for attorneys and claimants to fill
out and return to us.


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Created: January 24, 2000
Last Updated: May 28, 2000