A-1 VA WEST / Benefits Access & Financial Blueprint Form
Section 1: Basic Information
Full Name:
First Name
Last Name
Email:
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method:
Email
Text
Call
Section 2: Identify Yourself
I am a Veteran
I am a Civilian looking for financial education or support
I represent a business (50+ W-2 Employees)
Section 3: Veteran-Specific Questions (If Applicable)
Branch of Service:
Years of Service:
Last Duty Station Assigned:
Service Entry Date:
End of Service Date:
Please list any deployments you have participated in, including the location and dates of each:
Have you ever filed a VA Claim?
Yes
No
If yes, %:
Are you seeking assistance to file a claim?
Yes
No
When was the last time you logged into your VA.gov profile? Please provide the month and year:
month and year
Have you set up your ID.me account?
Yes
No
Will you need assistance logging into your VA.gov account
Yes
No
Section 4: Civilian/Supporter Questions
Are you interested in:
Learning to build wealth using IUL or trust-based tools
Supporting Veterans through your Subscription
Both
Are you already Subscribed?
Yes
No
Section 5: Business & Employer Questions
Business Name:
Total W-2 Employees:
Current Payroll System:
Interested in a savings analysis through our EmployWell Program?
Yes
No
Support Veterans through payroll savings?
Yes
No
Section 6: Program Interest
VA Disability Claim Assistance
Life Insurance / Wealth Planning
Business Structuring / Trust Setup
Business Credit & Funding Access
Nonprofit Partnership / Donation
Youth Financial Literacy Program
General Subscription & Newsletter
Section 7: Final Notes
Describe your goals or what you're hoping to accomplish:
Did someone refer you to A-1 VA Ratings West? Let us know who!
Consent to Contact
I consent to being contacted by A-1 VA WEST to assist with my inquiry
Upload VA decision letters and relevant medical documentation, if applicable
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Upload DD214, if applicable
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