Contact Me

Name*

Email*

Phone Number

What is your age?

Have you stopped working?---YesNo

If so, when?

What was your job title?

Have you applied for Social Security Disability benefits and/or SSI?---YesNo

Have you been turned down?---YesNo

What is the date of SSA’s most recent denial?

Have you applied for disability benefits under a private or employer provided long term disability insurance plan?---YesNo

Have you been turned down?---YesNo

What is the date of the insurance carrier’s denial letter?

Please tell me what illnesses, diseases or conditions keep you from working?