FREE Social Security Disability Claim Evaluation
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FREE Disability Claim Evaluation
Social Security Disability Questionnaire
Thank you for your interest in the services of Clifford M. Womack. So that we may better understand and evaluate your disability claim, please fill out the following quick form. We will contact you regarding you claim shortly. Your information will remain strictly confidential.
Name
*
First
Last
Email
Phone
*
Age
When did your condition first begin to affect you?
Less than a year ago
1-3 years ago
3-5 years ago
Over 5 years ago
Has your condition caused you to stop working or substantially reduce your work hours?
Yes, I have stopped working
Yes, I have reduced my work hours
No
At approximately what date did you stop working or reduce your work hours?
Have you applied for social security disability?
Yes, current claim pending
Yes, but no current claim (e.g. claim denied)
no
On approximately what date did you apply or was your previous claim denied?
Are you currently being treated by a doctor?
Yes
No
Please describe the physical and/or mental health conditions that interfere with your ability to do work:
How did you find out about us?
Captcha
Enter the math answer.
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Law Office of Clifford M. Womack
1751 River Run, Suite #211
Fort Worth, Texas 76107
info@attorneywomack.com
817-546-3888
CALL TODAY
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