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Claim Status:
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If denied, what level?
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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

Disability:

Physical / Mental Limitations:

Conditions & Symptoms:

Back Injury
Neck Injury
Hip Injury
Knee Injury
Foot Problems
Asthma
Bronchitis
Sleeping Problems
Depression Disorder
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ADD
ADHD

Heart Problems
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Bi-Polar
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Concentration Problems
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Are you being treated? Yes   No

Do you have an attorney? Yes   No

Is the injury work-related? Yes   No

Medications:

Other claims:
Workers Compensation
Long Term Disability
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