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Free Social Security Benefits Consultation
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Claimant's Name:
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Claimant's Telephone:
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Claimant's Email Address:
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*Please leave blank if you are the claimant
Claimant's Address:
City:
State, Zip:
Telephone Number:
Cell (Mobile) Phone:
If you are the claimant, please tell us the
best way to reach you:
Your Current Age:
Work History:
Are you presently working?
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*If Yes, please note, we cannot assist you if you are working
When did you stop working?
In the last 7 years, please tell us about your work activity:
Year
Full Year
Part of the year
Did not work at all
2009
2008
2007
2006
2005
2004
2003
Social Security Claim Status:
Have you applied for
Social Security Disability
(SSDI) in the last 18 Months?
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If yes, is the
claim still Pending?
Yes No Not Sure
If yes, at what level?
Was your claim denied?
Yes No Not Sure
If yes, at what level?
Give us the approximate
date of your last denial:
Please describe your disability:
Please tell us some of your
physical and mental limitations:
Conditions & Symptoms:
Back Injury
Neck Injury
Hip Injury
Knee Injury
Foot Problems
Asthma
Bronchitis
Sleeping Problems
Depression Disorder
Epilepsy
ADD
ADHD
If Yes, did you file a Workers
Compensation Claim?
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Are you receiving or have your
Received Workers Compensation?
Yes No
Do you have an attorney presently
assisting you in a Social Security
Disability (SSDI) claim?
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If Yes, why are you seeking our assistance?
Please list the medications you are taking:
Are you receiving any other types of benefits
listed below? *Please check all that apply:
Long Term Disability
Early Retirement From Social Security
Widow's Benefits From Social Security
Personal Injury Settlement
Medical Malpractice Settlement
Other
How did you become disabled?
*Please check all that apply
Natural Causes
Sickness/Illness/Disease
Medical Malpractice
Car Accident
Injury or Accident
Medication or Product
Other
If you chose "Medical Malpractice," "Car Accident,"
"Injury or Accident," "Medication or Product," or "Other"
Date of incident:
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City where incident occured:
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State where incident occured:
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What was the date of the incident?
What city did the incident occur in?
What State did the incident occur in?
Please tell us what happened. Be sure to include
all the facts including who was at fault and why:*
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If you found us using a search engine,
please tell us which search engine?
Please tell us exactly what terms you typed into the
search engine to find us? (i.e. Personal Injury Lawyers)
I understand that by filling out this free consultation form I am not forming an attorney client relationship. I understand that I may only retain an attorney by entering into a fee agreement and that by submitting this form I am not entering into a fee agreement. I understand that not all submissions may receive a response.
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I agree that the above does not constitute a request for legal advice. I agree that any information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. I agree that if this matter requires advice regarding my home state, local counsel may be contacted for referral of this matter. I understand that email is not secure and thus I am not forming a confidential relationship.
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