Your Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Contact Number *

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Are you seeking assistance with an overpayment or termination case?

Yes

No

Are you currently receiving any Social Security disability benefits?

Yes

No

Have you received a recent denial from Social Security?

Yes

No

Have you been previously been represented on this disability application?

Yes

No

Are you currently on / receiving any of the following?

Long-term disability

VA disability

Ongoing or recently settled workers' compensation case

SMI designation