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Claim Information

By submitting this claim information you are not entering into an attorney/client relationship. All information is kept confidential.

Name:
Telephone #:
Email Address:
Date of birth:
Have you applied for any Social Security disability benefits?		Yes No
Have you been denied?		Yes No
Date of most recent denial.
What does the denial letter say is the next step for you?
Reconsideration Hearing
Does this claim involve a disabled child?		Yes No
Have you stopped working?		Yes No
If yes, when did you stop?
If no, are you working full-time?		Yes No
Highest school grade completed:
If you did not graduate from high school, do you have a GED? ?		Yes No

Describe your disabling physical or mental condition:
Is your disabling medical condition the result of a work related injury?		Yes No

Are you receiving workers compensation benefits?		Yes No

Is there additional information we may need to know now?

Submit