1. Are you unable to work because of a mental or physical inpairment?

Yes No

2. Are you over whelmed by the paperwork involved in a claim for Social Security benefits?

Yes No

3. Have you been denied benefits once or twice?

Yes No

4. Did you start a claim years ago and let it drop when you were denied?

Yes No

5. Would you like to know how Workers Compensation benefits affect your ability to collect Social Security benefits?

Yes No

6. Have you been off work for at least 3 months and does it look like you will not be able to return to work soon?

Yes No

7. Would you like to know if there are time limits for applying for Social Security Disability and what the phrase "Date Last Insured" means?

Yes No

8. Would you like to know if waiting to apply for Social Security Disability benefits will make it more difficult to obtain Social Security Disability benefits?

Yes No

9. Are you a disabled child of a disabled worker and were you disabled before you became 21 years of age?

First option Second option Third option

10. Would you like us to contact you to discuss your potential SSD or SSI claim?

yes No

Name:

Address:

Phone Number:

To submit your answers and contact information to our office for a free evaluation, please press the "Submit free evaluation form" button below. A member of our firm will call you within 48 hours.