Free Social Security Disability Evaluation

Please fill out our Secure FREE Social Security Disability Form. One of our representatives will contact you within 2 business days.

 

EXISTING CLIENTS, PLEASE CALL (212) 365-5018

Title

Name

Email

Telephone Number

Address

Date of Birth (If you do not wish to enter your date of birth, please complete Age Range field)

Age Range

What type of doctors are you currently seeing? List all.

Do your doctors think you are disabled? If so, which ones

Are you currently working?

Yes No

Are you currently collecting Social Security benefits?

Yes No

Have you applied for Social Security Disability benefits?

Yes No

If yes, what is the status?

Approximate date last worked regularly

Approximate date became disabled

Tell us about your disability and/or issues. We welcome your calls, letters and electronic mail.

The information you obtain at this site is not, nor is it intended to be, legal advice. Contacting us via this web at www.binderandbinder.com is not retaining Binder & Binder®. Social Security does not consider us authorized to act on your behalf until you sign a retainer and the government form 1696 that says you want us to represent you. We cannot represent you without your signature on these forms. Social Security will not allow us access to your file until we submit their 1696 government form.

If there are deadlines to file an appeal, DO IT NOW. We cannot file any appeal nor can we act on your behalf until you retain us and authorize us to handle your social security case.


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BINDER & BINDER®

HELPING THOUSANDS OF CLIENTS EVERY YEAR

Office:
1-800-66-BINDER
Retained Before December 2016