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CPT Case Submission Form
Hello! Thank you for considering CPT. Before we begin, we will need some basic information.
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* Indicates required question
Email
*
Your email
Your Full Name
*
Your answer
Role
*
Disabled Individual/Family Member
Workers Compensation Attorney
Personal Injury Attorney
Trust & Estate Planning Attorney
Special Needs Planning Attorney
Structured Settlement Broker
Other:
Contact Number
*
Your answer
Best time to call?
Your answer
Case Name
Your answer
Is the individual disabled?
Yes
No
Unknown
Is the individual unable to work?
Yes
No
Unknown
Is the individual receiving Supplemental Security Income (SSI)?
Yes
No
Unknown
Is the individual receiving Medicaid?
* Please note: Some states refer to their Medicaid program by a different name. Ex: CA = Medi-Cal
Yes
No
Unknown
Is the individual receiving Medicare?
Yes
No
Unknown
Is the individual receiving Social Security Disability Insurance (SSDI)?
Yes
No
Unknown
Is the individual over the age of 64?
Yes
No
Unknown
Clear selection
You're done!
*Remember: The only documentation required prior to a trust signing is a signed Social Security. Our bank will not accept funds without this document.
A copy of your responses will be emailed to the address you provided.
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