Information
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Qualify
2
Result
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First Name
Last Name
Email Address
Phone Number
Date of Birth - mm/dd/yyyy
Zip Code
Please Describe Your Condition
Do I Qualify?
Do you expect to be out of work for at least 12 months?
?
Yes
No
Have you worked for at least 5 of the last 10 years?
Yes
No
Are you currently working and making more than $1,470/month?
?
Yes
No
Are you prescribed medication or being treated by a doctor?
?
Yes
No
Do you already receive some Social Security benefits?
?
Yes
No
Do you already have a Social Security attorney or advocate?
?
Yes
No
Do you need to speak with a Social Security attorney or advocate?
Yes
No
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See My Results
Were you physically injured in an accident that wasn't your fault?
Yes
No
What type of accident caused your injury?
-- Please Select One --
Auto Accident
Motorcycle Accident
18-Wheeler Accident
Work Accident
Dog Bite/Animal Attack
Slip and Fall
Pedestrian
Bicycle/Scooter Accident
Injury During Active Duty
Other Accident
Date of your accident? (your best guess is fine)
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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31
Year
Was the accident your fault?
Yes
No
Do both parties have insurance coverage?
Yes
No
Did you need at least a week off work to recover?
Yes
No
Are you a federal employee?
Yes
No
Did your injury require immediate medical attention?
Yes
No
Estimated Medical Bills:
-- Please Select One --
None
$1-$10,000
$10,000-$25,000
$25,000-$50,000
$50,000-$100,000
$100,000 or more
Did the accident cause hospitalization, medical treatment, surgery or missed work?
Yes
No
Do you know who owns the animal that attacked you?
Yes
No
Do you have a disability that was caused while on active duty in the US Armed Forces?
*
Yes
No
Have you had a claim denied within the past 12 months?
*
Yes
No
Are you currently receiving VA retirement benefits?
*
Yes
No
Are you still working?
*
Yes
No
Do you already have a lawyer handling your injury case?
Yes
No
Briefly describe the injury and the incident that caused it.
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