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If you have questions regarding your claim or would like to be informed of your rights, please fill out the form below. After receiving your information, we will evaluate your claim and contact you within two business days.

There is no cost or obligation for this service and all information will remain strictly confidential.

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Work Phone: Mobile Phone:

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Date of Birth: 

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Claim Status:
Have not applied
Have applied but have not received a determination
Have applied and been denied
At original claim
At reconsideration
At hearing stage

How many times have you previously filed?
1   2   3   4   5 or more

If denied, what level?
Administrative Law Judge
Appeals Council

Most recently denied:  

Date you became disabled:  

Have you worked 5 out of the last 10 years? Yes   No

Last date you worked:  

Are you working? Yes   No


Physical / Mental Limitations:

Conditions & Symptoms:
Back Injury
Neck Injury
Hip Injury
Knee Injury
Foot Problems
Sleeping Problems
Depression Disorder  
Heart Problems
Poor Circulation
Nerve Problems
Mental Illness
Anxiety Disorder
Panic Attacks
Multiple Sclerosis
Concentration Problems
Memory Problems

Are you being treated? Yes   No

Do you have an attorney? Yes   No

Is the injury work-related? Yes   No


Other claims:
Workers Compensation
Long Term Disability
Personal Injury
Medical Malpractice

Case Information:
Case Description:
Comments/Additional Information:

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