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You may contact us by email at postmaster@disabilityapplicationhelp.org

The form below allows you to request a Free disability benefits evaluation. Complete the form below and a disability attorney will review your case and call you to let you know if you may be eligible for benefits.

Free Evaluation

Applicant's Information

First Name

Last Name

* Name:

Street Address:

* City:

* State:

* Zip Code:

* Phone:

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* Confirm Phone Number:

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* Email Address:

* Date of birth:

* Does applicant expect to be out of work for at least 12 months?

YesNo

* Does applicant already receive Social Security benefits?

YesNo

* Is an attorney helping applicant with this case?

YesNo

* Is applicant a Veteran?

YesNo

* Is applicant currently under the care of a doctor?

YesNo

* How many years has applicant worked in the last 10 years?

* What is the medical condition that prevents applicant from working?

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By clicking “Submit”, I hereby consent to receive autodialed and / or pre-recorded phone calls and / or SMS Messages (for which standard rates may apply), from an attorney at the telephone number(s) provided above, even if that phone number is a wireless number and even if you have previously registered that phone number on a “do not call” list. I understand that consent is not a condition of purchase.

Privacy and Security Notice: Your personal information is strictly confidential and secure.

Upon submitting this form, you will receive a phone call shortly during regular business hours. A disability attorney will give you a free evaluation of your disability claim.

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This website provides a free disability consultation by an experienced disability attorney. This website is not affiliated in any way with the Social Security Administration. If you wish to find or get help at the social security administration website, please go to ssa.gov. This website is attorney advertising. This is not a lawyer referral service. Advertising is paid for by participating attorneys. This website does not endorse or recommend any lawyer, or law firm who participates in the network. It does not make any representation and has not made any judgment as to the qualifications, expertise or credentials of any participating lawyer. No representation is made that the quality of the legal services to be performed is greater than the quality of legal services performed by other lawyers.