Social Security Form



Please take a moment to fill out this form. When you have completed the form, click the "send" button and a member of our staff will contact you to discuss your case as soon as we have reviewed your information.

Personal Information
* - indicates required information
Mr. Mrs. Ms.
Your Name:
 *
Address:
City:
County:
State:
Zip/Postal Code:
Home Phone:
 *
Work Phone:
Cell Phone:
Email:
(ex:johnsmith@abcd.com)
Your Employer:
Employer Address:
Social Security Information
Have you filed for Social Security Disability?   Yes No
If no, call 1-800-772-1213 and file your claim. When you are denied call us.
If you do have a claim, what is the date of your denial letter?
**Please note you have sixty (60) days from the date of the denial to file your appeal. If it has been more than sixty (60) days, re-file your claim by calling 1-800-772-1213, wait for your denail letter and contact us again.

Please make sure that all required fields are filled out and that all your information is correct.
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