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Nursing Home Negligence

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Social Security

If you are disabled from performing substantial gainful activity you may be eligible for Social Security Disability, SSDI or Supplemental Security Income, SSI Benefits. Unfortunately, the Social Security Administration often denies truly disabled claimants. All too often, it takes an attorney with knowledge of the laws and medical listings, to get disabled claimants benefits.  If you have questions regarding your Social Security case, or would like to receive a free evaluation of your claim, we invite you to ask an attorney. A lawyer will personally read your form and may contact you to discuss your rights.

Free Social Security Consultation

Your Name: *
Your Telephone Number: *
Your Email Address: *

If you are not the claimant, please tell us the
best way to reach you:

If you are not the claimant, please tell us your
relationship to the person you are inquiring for:

Please note, we cannot properly consider your
case without a valid e-mail address.

Claimant's Name: *
Claimant's Telephone: *
Claimant's Email Address: *

*Please leave blank if you are the claimant
Claimant's Address:
City:
State, Zip:   
Telephone Number:
Cell (Mobile) Phone:

If you are the claimant, please tell us the
best way to reach you:
Your Current Age:

Work History:
Are you presently working? Yes   No
*If Yes, please note, we cannot assist you if you are working
When did you stop working?
In the last 7 years, please tell us about your work activity:

Year Full Year Part of the year Did not work at all
2009
2008
2007
2006
2005
2004
2003

Social Security Claim Status:

Have you applied for 
Social Security Disability 
(SSDI) in the last 18 Months? 		Yes   No

If yes, is the 
claim still Pending?
Yes   No   Not Sure
If yes, at what level?

Was your claim denied?
Yes   No   Not Sure
If yes, at what level?

Give us the approximate 
date of your last denial:
 

Please describe your disability:
Please tell us some of your
physical and mental limitations:

Conditions & Symptoms:
Back Injury
Neck Injury
Hip Injury
Knee Injury
Foot Problems
Asthma
Bronchitis
Sleeping Problems
Depression Disorder  
Epilepsy
ADD
ADHD 		Heart Problems
Poor Circulation
Nerve Problems
HIV
Hepatitis
Mental Illness
Anxiety Disorder
Panic Attacks
Bi-Polar
Multiple Sclerosis
Concentration Problems
Memory Problems

Is a doctor currently treating you?
Yes    No
If no, why not?
Is the injury work-related? Yes    No
If Yes, did you file a Workers 
Compensation Claim? 		Yes    No
Are you receiving or have your 
Received Workers Compensation? 		Yes    No
Do you have an attorney presently 
assisting you in a Social Security 
Disability (SSDI) claim? 		Yes    No
If Yes, why are you seeking our assistance?
Please list the medications you are taking:


Are you receiving any other types of benefits
listed below? *Please check all that apply:

Long Term Disability
Early Retirement From Social Security
Widow's Benefits From Social Security
Personal Injury Settlement
Medical Malpractice Settlement
Other


How did you become disabled?
*Please check all that apply

Natural Causes
Sickness/Illness/Disease
Medical Malpractice
Car Accident
Injury or Accident
Medication or Product
Other

If you chose "Medical Malpractice," "Car Accident,"
"Injury or Accident," "Medication or Product," or "Other"
Date of incident:   *
City where incident occured: *
State where incident occured: *
What was the date of the incident?  
What city did the incident occur in?
What State did the incident occur in?   

Please tell us what happened. Be sure to include
all the facts including who was at fault and why:*

To Better Serve You:

Please tell us how you found us? If "other" please specify.
Please specify how you found us (if other than above):
If you found us using a search engine,
please tell us which search engine?
Please tell us exactly what terms you typed into the
search engine to find us? (i.e. Personal Injury Lawyers)
I understand that by filling out this free consultation form I am not forming an attorney client relationship. I understand that I may only retain an attorney by entering into a fee agreement and that by submitting this form I am not entering into a fee agreement. I understand that not all submissions may receive a response.
Yes   No
I agree that the above does not constitute a request for legal advice. I agree that any information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. I agree that if this matter requires advice regarding my home state, local counsel may be contacted for referral of this matter. I understand that email is not secure and thus I am not forming a confidential relationship.
Yes   No
I have read and agree with the TERMS AND CONDITIONS
Yes   No

By Clicking the box below, I agree to submit my case for a free case evaluation:



* = Required Fields

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