Answer the information below if you are under the age of 65 with a medical condition expected to last 12 months, have documentation to support your condition, and have worked 5 out of the last 10 years. Once you have completed the Free Case Evaluation Form, click Submit and one of our representatives will contact you within 24 - 48 hours from the time of submission. For faster service, contact us directly at 877-610-5429 between 9 a.m. and 6 p.m. (EST) to process your free case evaluation over the phone with one of our friendly representatives.


Free Case Evaluation Form
* indicates required fields 
  *First Name:
  Middle Initial:
  *Last Name:
  *Address 1:
  Address 2 (Apt. or Unit #):
  *City:
  *State:
  *Zip Code:
  *Phone (Area Code + Number):
  Cell:
  E-mail:
  *Birthdate (MM/DD/YYYY):
  *Age:
  Gender:  Male
 Female
  *I need help:  applying for the first time
 appealing a denial
 applied but have not received a decision letter
  *Primary Diagnosis (Ailment):
  *Secondary Diagnosis (Ailment):
  *Highest Level of Education:
  *Have you been incarcerated?:  No
 Yes
  *Are your ailments medically documented?:  No
 Yes
  *Are your ailments progressive (ex: getting worse)?:  No
 Yes
  *Do you have multiple impairments? (ex: 2 or more):  No
 Yes
  *Do you have severe pain?:  No
 Yes
  List Prescription Medications ( 1 per line):
  *Do you have side affects from your medications?:  No
 Yes
  *Do your impairments affect both sides of the body?:  No
 Yes
  *Have you been hospitalized due to your impairment?:  No
 Yes
  *Have you had any surgeries due to your impairment?:  No
 Yes
  *Are you limited in your ability to walk or stand?:  No
 Yes
  *Do you have problems sitting?:  No
 Yes
  *Do you have hand limitations?:  No
 Yes
  *Do you have visual limitations?:  No
 Yes
  *Do you have hearing limitations?:  No
 Yes
  *Do you use a medical device? (ex: prosthesis):  No
 Yes
  *Do you suffer from a mental disorder?:  No
 Yes
  *Do you have any disfigurements?:  No
 Yes
  *Are you currently employed?:  No
 Yes
  Date Employment Ended (MM/DD/YYYY):
  Last position held (ex: job title):
  *Average Annual Income:
  Describe the physical requirements of last job:
  Briefly describe how your impairments prevent work:
  Briefly describe your current daily activities:
  When is the best time to contact you?:
 

Disclaimer: We are independent benefit consultants or non-attorney representatives authorized by law to represent claimants before the Social Security Administration from the Initial application to the Administrative Law Judge Hearing level. We are in no way directly affiliated with the Social Security Administration.

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