Phone:(973)716-0888 Fax:(973)716-0222 info@disabilitycounsel.com Contact Us > Print Blank Form > Print Your Completed Form Name: Street Address: City, State: Zip Code: Daytime Telephone: Fax Number: Did you receive a letter denying benefits: If so, when? What company sent you the denial letter? Name of company: What is the deadline for an appeal or litigation? Deadline date: Email where we can contact you with questions we may have? Email: What would you like our lawyers to help you with: Please describe what conditions disable you: Comments: (you may also email us separately from this form and provide more details if you wish or call us directly.)