Information

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Please Answer the Questions Below For a FREE Benefits Evaluation

First Name

Last Name

Email Address:

Phone Number:

AGE

Zip Code

Do you expect to be out of work for at least 12 months? Yes No

Are you currently working? Yes No

Have you worked for at least 5 of the last 10 years? Yes No

Are you prescribed medication or being treated by a doctor? Yes No

Do you already receive some Social Security benefits? Yes No

Do you already have a Social Security attorney or advocate? Yes No

Do you need to speak with a Social Security attorney or advocate? Yes No

Please select your health issue(s) below: (Check all that apply) Back Pain Heart Conditions Mental Conditions Diabetes Lung Conditions Cancer Obesity Arthritis Organ Failure Other

Please add any additional details:

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Were you physically injured in an accident that wasn't your fault?

What type of accident caused your injury?

Date of your accident? (your best guess is fine)

Was the accident your fault? Yes No

Do both parties have insurance coverage? Yes No

Did you need at least a week off work to recover? Yes No

Are you a federal employee? Yes No

Did your injury require immediate medical attention? Yes No

Estimated Medical Bills:

Did the accident cause hospitalization, medical treatment, surgery or missed work? Yes No

Do you know who owns the animal that attacked you? Yes No

Do you have a disability that was caused while on active duty in the US Armed Forces? * Yes No

Have you had a claim denied within the past 12 months? * Yes No

Are you currently receiving VA retirement benefits? * Yes No

Are you still working? * Yes No

Do you already have a lawyer handling your injury case? Yes No

Briefly describe the injury and the incident that caused it.

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