Answer the information below if you are under the age of 65 with a medical condition expected to last 12 months, have documentation to support your condition, and have worked 5 out of the last 10 years. Once you have completed the Free Case Evaluation Form, click Submit and one of our representatives will contact you within 24 - 48 hours from the time of submission. For faster service, contact us directly at 877-610-5429 between 9 a.m. and 6 p.m. (EST) to process your free case evaluation over the phone with one of our friendly representatives.
Free Case Evaluation Form
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indicates required fields
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First Name:
Middle Initial:
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Last Name:
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Address 1:
Address 2 (Apt. or Unit #):
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City:
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State:
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Zip Code:
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Phone (Area Code + Number):
Cell:
E-mail:
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Birthdate (MM/DD/YYYY):
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Age:
Gender:
Male
Female
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I need help:
applying for the first time
appealing a denial
applied but have not received a decision letter
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Primary Diagnosis (Ailment):
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Secondary Diagnosis (Ailment):
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Highest Level of Education:
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Have you been incarcerated?:
No
Yes
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Are your ailments medically documented?:
No
Yes
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Are your ailments progressive (ex: getting worse)?:
No
Yes
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Do you have multiple impairments? (ex: 2 or more):
No
Yes
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Do you have severe pain?:
No
Yes
List Prescription Medications ( 1 per line):
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Do you have side affects from your medications?:
No
Yes
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Do your impairments affect both sides of the body?:
No
Yes
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Have you been hospitalized due to your impairment?:
No
Yes
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Have you had any surgeries due to your impairment?:
No
Yes
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Are you limited in your ability to walk or stand?:
No
Yes
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Do you have problems sitting?:
No
Yes
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Do you have hand limitations?:
No
Yes
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Do you have visual limitations?:
No
Yes
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Do you have hearing limitations?:
No
Yes
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Do you use a medical device? (ex: prosthesis):
No
Yes
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Do you suffer from a mental disorder?:
No
Yes
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Do you have any disfigurements?:
No
Yes
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Are you currently employed?:
No
Yes
Date Employment Ended (MM/DD/YYYY):
Last position held (ex: job title):
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Average Annual Income:
Describe the physical requirements of last job:
Briefly describe how your impairments prevent work:
Briefly describe your current daily activities:
When is the best time to contact you?: