Submit Case for Evaluation

Social Security Disability Form

Using a form is helpful, but not required. You can always contact us or call us at 207-780-6700 or toll free at 800-425-6700.

Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Please briefly describe the circumstances surrounding your injury

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Age

Number of Dependants

Social Security Number

How were you referred?

Nature of Disability

Have you worked for 5 out of the last 10 years?

Yes

Please list the names of the doctors who have treated you for your injury

What state of the application process are you in?