Social Security Disability

Free Legal Consultation

At Edgar Snyder & Associates, we offer a free initial legal consultation. If we don't think you need an attorney, we will tell you so. If you believe that you, or someone close to you, may have a claim, you may contact us in one of two ways:

• Complete and submit the online form below or
• call us toll free at 1-866-867-9914. Our phones are answered 24 hours a day, 7 days a week.

Remember: There is no charge for this consultation and no obligation to use our services. And, as always, at Edgar Snyder & Associates, "there's never a fee unless we get money for you!"

* Questions marked in red are required

Your Contact Information
First Name:
Last Name:
Street Address:
City:
State:	state AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip/Postal Code:
Phone Number:	- -
E-mail Address:

Social Security Disability Claimant Information
For whom are you inquiring?	self spouse child parent relative friend
Name of claimant (if different than above):
Claimant's Date of Birth:	mm 01 02 03 04 05 06 07 08 09 10 11 12 dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Is there currently an attorney handling this matter?	yes no
Marital Status:	select single married separated divorced

Disability Background
Employment
Please briefly describe your work history over the past 10 years. Be sure to include job title(s) and lengths of employment.
What is your present means of support?	select spouse pension short/long term disability public assistance workers compensation other
What's your total monthly income?	$ (ex: 500)
Education
Highest level of education completed?	select Junior High School High School Diploma GED Some College Associate's Degree Bachelor's Degree Master's Degree Ph.D.
Are you currently attending school?	yes	no
Do you have any learning disabilities?	yes	no

Please describe your disability.
List the doctors that you are currently treating with:
Has a doctor told you that you're disabled?	yes	no
If you answered yes, what is the doctor's name?:

Please list medications that you are currently taking as a result of your disability.
Have you received workers' compensation benefits in the past?	yes	no
Do you have a history of substance abuse?	yes	no
Do you smoke cigarettes or have a history of smoking?	yes	no

Social Security Disability Claims Process
Have you applied for Social Security Disability?	yes	no
Have you had a hearing for Social Security Disability?	yes	no
After the hearing were you denied Social Security Disability Benefits?	yes	no
If you were denied benefits, have you filed an appeal to the Appeals Council?	yes	no

Additional Information
How did you find our website?
Search Engine or Website select AOL AltaVista Google Lycos MSN YAHOO! Other Search Engine wjactv.com wpxi.com Other Website
Television Ad Radio Ad Referred by a Friend	Newspaper Ad Billboards Other
Are there any other questions you wish to have answered?
Send me breaking news on dangerous drugs and product recalls that could impact me and my family. No thank you.

Thank you for allowing Edgar Snyder & Associates to provide you with a free evaluation of your Social Security Disability claim. Please remember:

• Many times, in order to give you a complete evaluation of your claim, we will need to speak with you on the telephone. Therefore, when completing the information above, please be sure to provide us with a telephone number where you can be reached.
• Submission of this form and the information contained in it is not privileged nor is it intended to create an attorney-client relationship between the sender and Edgar Snyder & Associates.
• Your information will be reviewed during normal business hours, M-F 8:30am - 5:00pm.

Disclaimer | Privacy Policy | Search | Site Map | Contact Web Master