Case Type Case TypeAUTO ACCIDENTMOTORCYCLE ACCIDENTTRUCK ACCIDENTPERSONAL INJURYWORKPLACE INJURYSS DISABILITYWRONGFUL DEATHELDER ABUSECAMP LEJEUNECLASS ACTIONOTHER

Your First Name

Your Last Name

Street Address

City

State

Zip

Email Address

Phone Number

Is This Inquiry For You or Are You Inquiring As The Parent / Guardian Of A Child? Is This Inquiry For You or Are You Inquiring As The Parent / Guardian Of A Child? CHILD ADULT

Enter Date of Birth of Claimant

Have You Already Submitted an SSD Claim And Been Denied? Have You Already Submitted an SSD Claim And Been Denied? NO YES

What Was The Date Of Denial?

Are You Currently Working? Are You Currently Working? NO YES

When Was The Date You Last Worked?

What Medical Problems Impact Your Ability To Work?

What Is The Child's Full Name?

What Is The Child's Date of Birth?

Has The Child Already Had An SSD Claim Denied? Has The Child Already Had An SSD Claim Denied? YES NO NOT SURE

What Date Was The Denial?

Does The Child Attend School? Does The Child Attend School? YES NO

What Grade Is The Child In At School?

Does The Child Have an IEP Or Receive Special Edu Services? Does The Child Have an IEP Or Receive Special Edu Services? YES NO NOT SURE

Any Other Information To Help Us Assess Your Case?

Describe Your Situation Briefly: