Interview Request Representative

Complete The Disability Representative Interview Request Form Below To Learn How A Representative Could Maximize Your Chances Of Winning Benefits.

First Name *

Last Name *

Email *

Gender *

State *

Phone *

1. Have You Applied for Disability Yet? *

2. Date you last worked fulltime 00/0000 *

3. Have you worked 50 % or more of the last 10 years? *

Yes No

4. Are you working with an attorney or non attorney representing your case? *

5. Are you under Doctors care? (yes or no) *

6. Will your condition last more than a 1 year? (yes or no) *

7. Are you (over or under) 50 years old?

8. Explain why are not able to work any job in the USA 5 days a week 40 hours a week and what is most important to you. *

9. What is the best 60 minute time frame to schedule your interview. *

10. First available day for your interview *

Disclaimer: When you select submit you agree and understand that approval times may vary. If not using a disability representative you will be scheduled for a no obligation interview. All qualified for disability based on information provided will be sent the Disability approval course. There is no charge for your Disability Digest Membership.