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Social
Security Disability Inquiry Form - Adult |
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* Required |
| Your Name* |
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| Social
Security No.* |
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| Date of
Birth* |
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| Phone
Number(s)* |
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| Address |
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| E-Mail* |
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| Highest
School Year* |
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| Kind of
Work Done Over Last 20 Years |
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| Heaviest
Job and Amount Lifted |
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| At What
Level Is Your Case?*
Remember: 60-Day Deadline
to Appeal Denied Cases
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| If
Your Hearing Is Scheduled, Tell Us: |
Date:
Time:
Judge: |
Location:
Hartford
New Haven
Springfield |
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Where Did You
File Your Case? |
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Massachusetts:
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| Click Which
Of These Conditions You Have |
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| Please Tell
Us About Any Other Medical Problems You Have |
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Click Which
of These Hospitals You Have Gone To |
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Massachusetts:
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| Tell Us
Your Doctors
Include Name, Address, Telephone |
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| Tell Us
Your Prescription Medications |
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Please include the area codes for
your phone number(s).
Please note that with this form you are only
sending us information.
To hire us as your attorney you must sign a
contract with us to represent you in this matter.
Thank you for sending us this information.
