Thank you so much for contacting our disability claims office! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security Number and other personal information will only be used in the event that you hire the firm to represent you in your disability matter, and then only when necessary in limited use during the course of your case.

Social Security Numbers are most often used to positively identify parties. All claims require Social Security Numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in connection with benefits
in required reports or other documents filed with the Social Security Office and the Office of Veteran Affairs

If you have any questions, please don't hesitate to contact our office. We look forward to working with you!

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.

Contact information

Preferred Contact Method

Gender

Social Security Number

Date of Birth

Marital Status

Are you currently employed?

Dates of Service

Branch of Service

MOS

Please list all Disabilities that you are service connected for and the rating.

Please List All Conditions that you have applied for and been denied, and the dates of those notices (You can download the VA Benefits and health App. and the information under the disabilities section/Disability percentage/ There it will list everything connected and not connected and the dates.

Do you have dependents that are not added to your claim?

Add Emergency Contact Information

Significant Awards (Navy Cross, Distinguished Service, Medal of Honor, Combat Action)

Place of Birth

Mother's Maiden Name

Housing Status

Have you ever been a POW?

Please attach any communication from the VA you have here

Add Any Service Records Here DD214

Add any Buddy Statements Here

Add Any Medical Records you have that the VA does not have

Drivers License Photo Here

Marriage Certificate

Please acknowledge that you have read and hereby accept the above privacy policy regarding use of my personal information by typing your full legal name below

THANK YOU