DO I HAVE A CLAIM?

Name:

Age:

Address:

Telephone:

Email :

Education Level:

How Did You Get Our Phone Number?:

Have Been Denied Benefits :
YesNo

If Yes, What Is The Date Of The Denial Decision? :

Did You Appeal Your Denial Decision?:
YesNo

If Yes, When Did You Appeal Your Decision?:

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? :

Have You Or Will You Receive Any Type Of Unemployment Benefits :
YesNo

If Yes, Are You Still Collecting Payments?:
YesNo

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?:

Have You Or Will You Receive Ttd Benefits?:
YesNo

If Yes, Are You Still Collecting Ttd Payments?:
YesNo

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?:
YesNo

Have You Received A Lump Sum Settlement From Workmans Comp?:
YesNo

If Yes, When Did You Receive Your Lump Sum Settlement?:

Are You Getting Any Type Of Social Security Payments, I.E., Ssi, Ssdi, Retirement:
YesNo

If Yes, When Did Your Payemnts Start:

Have You Collected Ssi Or Ssdi In The Past:
YesNo

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?: