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Please complete as many fields as are appropriate to your (or your client's) case. Bold fields are mandatory. We will review your information and respond to you in a timely manner (US citizens only, please).
Name
Address
City ST Zip
Phone
E-mail
Date of Birth
Education completed
Other Education
Description of past job
Job skills learned
How long held?
Reason for leaving
Date last worked
Any work since last job, even part time? Yes    No
Dates employed    Earnings per month
Type of work
Description of medical problems and how they affect work
Have you (or client) worked at least 5 of the last 10 years in jobs where taxes were paid? Yes    No
Status of Social Security claim (select and complete all that apply)
Haven't applied yet
Applied but no decision    Date applied
Received first denial? Date
    Appealed? Date
Received second denial? Date
    Appealed? Date
    Hearing scheduled? Date Location
    Claim denied after hearing - Date
         Appealed? Date
    Appeals Council denial? Date
    Federal court suit filed? Date
Any prior applications for SSD? Yes    No
Dates   Actions taken
Private Disability Insurance
Any private insurance for disability? Yes    No
    Provided by employer or self obtained?
Name of disability insurance company
Currently receiving benefits? Yes    No
    Monthly amount? Date started receiving
Medical treatment (Pick all that apply)
    General practice (family) physician
    Allergist
    Immunologist
    Environmental Medicine/Clinical Ecologist
    Rheumatologist
    Psychiatrist or psychologist
    Osteopathic (D.O.)
    Chiropractic (D.C.)
    Other types of health practitioners
Workers Compensation Benefits (select one)
Currently receiving benefits    Amount weekly
    Date started Date ended
Case pending    Where
Case closed    Settlement amount Date
Worker's Comp Attorney name (if applicable)
Other Legal Action
Personal injury case pending? Yes    No
Attorney
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