Form

Information
1

Qualify
2

Result
3

Please Answer the Questions Below For a FREE Benefits Evaluation

First Name

Last Name

Preferred Phone Number

Age

Zip Code

Do you expect to be out of work for at least 12 months?

Yes

This field is required

Have you worked for at least 5 of the last 10 years?

Yes

This field is required

Do you already receive some Social Security benefits?

Yes

This field is required

HAVE YOU SEEN A DOCTOR IN THE LAST YEAR?

Yes

This field is required

Do you already have a Social Security attorney or advocate?

Yes

This field is required

Please select your health issue(s) below: (check all that apply)

Back Pain Heart Conditions Mental Conditions Diabetes

Cancer Obesity Arthritis Other

This field is required

Would you like to receive text messages regarding your evaluation?

Yes

By submitting your request, you grant permission for disabilityhelpsolutions.com or their partners to contact you by phone, text messaging and/or email using the phone number or email address that you provided so we may assist you with your request for a free case evaluation and that these partners may use an automatic telephone dialing system even if the number provided is a wireless line. Being contacted is not a condition of purchase or acceptance of services of any kind.

Optional:

Have you been injured in an Auto Accident?

Auto Injury CLAIM DETAILS:

Complete this section if you would like help with your injury claim.

Approximate date of Injury?

This field is required

Was the injury someone else's fault?

Yes No

This field is required

Have you been treated by a doctor in the last 90 days due to the accident?

Yes No

This field is required

Do you already have legal representation for your auto accident case?

Yes No

This field is required

Do you want a free auto accident consultation? (this is separate from your disability consultation)

Yes No

This field is required

Please describe your injuries:

This field is required

No Thanks

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