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Submit Your Claim

Please fill out this form and submit it for a free case evaluation. We will contact you by the next business day. Required fields are in red, with an asterisk.

After you submit this form you should get an auto-response e-mail to let you know that we received it. If you do not, please call us at one of the phone numbers at the left of this page.

*Title:
*First Name:
*Last Name:
Address:
City:
*State:
Zip Code:
Phone:
Alternate Phone:
*Email address:
*Date of Birth:
Sex:
Marital Status:
Are you filling out this form for somebody else? If so, please enter:
Your Name:
Your Phone:
*Claim Status:
How many times have you previously filed a claim?
If you have been denied, at what level:
Approximate date you were most recently denied:
What type of claim do you have?
Approximate date you became disabled:
Have you worked at least 5 of the last 10 years? Yes No Don't Know
Approximate date you last worked:
What was your most recent job?
*Describe your disabilities and your physical and mental limitations:
*Are you being treated by a doctor now? Yes No
Does your doctor know you are filing for disability? Yes No
*Do you have an attorney for this claim? Yes No
Is your injury or disease work-related? Yes No
Are you also making a workers’ compensation, personal injury or other type of claim?
Do you have any questions or comments?
*Yes No  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 written fee agreement and that by submitting this form I am not entering into a fee agreement.

I agree that the above does not constitute a request for legal advice.
   

 

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