Social Security Disability Eligibility Survey

Wonderful! Please fill out the survey below. Please be extremely honest with your answers. This will help us to accurately determine where you are in the process and if we are able to assist you.

SSD - Qualification Form

Let's start by gathering some information.

First Name

Last Name

Phone/Mobile

Is your case for an adult or child?

Adult

Child

Based on the information you have provided, please call our office immediately and speak with our Social Security Disability legal team at 1-800-587-8423.

Have you worked and paid social security taxes in the last 5 years?

Yes

Are you currently earning $1350 or more per month BEFORE taxes?

Yes

Based on the information you have provided, we are currently unable to represent you at this time. By law, when seeking Social Security Disability, your earnings may not exceed $1350 per month.

Have you been treated by a medical provider for any physical or mental condition within the last 6 months?

Yes

Based on the information you have provided, we are currently unable to represent you at this time. Our law firm's policy requires all our clients to be receiving medical treatment within the last 6 months.

Have you been denied social security disability or supplemental seccurity income benefits within the last 60 days?

Yes

Based on the information you have provided, we are currently unable to represent you at this time. Social Security regulations allow for a time not exceeding 60 days, to file an appeal, due to a denial of benefits.

Are you currently receiving any retirement or disability benefits from the Social Security Administration?

Yes

Based on the information you have provided, we are currently unable to represent you at this time. Our law firm assists individuals whose benefit applications have been denied. If you are already receiving benefits, we most likely not be able to assist you.

Are you receiving any workers' compensation or long term disability benefits from an insurance carrier?

Yes

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