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(800) 608-8881
DO I HAVE A CLAIM?
Name:
Age:
Address:
Telephone:
Email :
Education Level:
How Did You Get Our Phone Number?:
Disability Denial Information
Have Been Denied Benefits :
Yes
No
If Yes, What Is The Date Of The Denial Decision? :
Did You Appeal Your Denial Decision?:
Yes
No
If Yes, When Did You Appeal Your Decision?:
Employment
When Was The Last Time You Worked?:
What Type Of Work Did You Do?:
Prior To That What Type Of Work Did You Do?:
For How Long? :
Unemployment Benefits
Have You Or Will You Receive Any Type Of Unemployment Benefits :
Yes
No
If Yes, Are You Still Collecting Payments?:
Yes
No
If Yes, How Much Are Your Payments?:
Prior To That What Type Of Work Did You Do?:
If Yes, But Payments Stopped, When Did You Receive Your Last Payment?:
Workmans Comp Beneftis
Have You Or Will You Receive Ttd Benefits?:
Yes
No
If Yes, Are You Still Collecting Ttd Payments?:
Yes
No
If Yes, How Much Are Your Payments?:
If Yes, But Payments Stopped, When Did You Receive Your Last Payment?:
If Payments Are Stopped, Is Your Case Still Pending?:
Yes
No
Have You Received A Lump Sum Settlement From Workmans Comp?:
Yes
No
If Yes, When Did You Receive Your Lump Sum Settlement?:
Disability
Are You Getting Any Type Of Social Security Payments, I.E., Ssi, Ssdi, Retirement:
Yes
No
If Yes, When Did Your Payemnts Start:
Have You Collected Ssi Or Ssdi In The Past:
Yes
No
If Yes, Why Did You Stop Getting Payments:
What Are Your Disabilities?:
How Does Your Disabilities Affect Your Ability To Work?:
When Were Your Disabilities Diagnosed?:
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