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For a FREE Disability Case Review
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• 1. Basic Questions
• 2. Disability Information
• 3. Contact Information

Are you currently working?	Yes No
How many hours per week?
Have you applied for Social Security Disability/SSI?	Yes No
If yes, have you been denied?	Yes No
If yes, when were you denied?
If yes, have you appealed?	Yes No
Is an attorney helping you with your Social Security Disability Claim?	Yes No
Will your condition prevent you from working full-time for at least 12 months?	Yes No
Your date of birth:	mm/dd/yyyy
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Describe your disability *
Is your condition work related?	Yes No
Will a doctor verify that you are unable to work?	Yes No
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Address
Zip Code	*	City
Email	*
Phone	*	Secondary Phone
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