Warrior Canine Connection SSDI Qualification Questionnaire

1

Military Time Served (hidden)

2

months

3

What is your name as it appears on your Social Security Card?* This field is required.

First Name

Last Name

4

Today's Date (Hidden)

Date

5

There are 3 requirements to qualify for SSDI:

You have to be of age.
You must have worked long enough and recent enough.
You must meet the definition of disability.

6

What Is Your Date of Birth?* This field is required.

7

Calculated Age

8

Have you worked a total of {served} {months}?* This field is required.(Including active military service)

YESNO

9

Are you receiving any benefits from Social Security?* This field is required.

YESNO

10

Have you applied for Social Security Disability in the last 3 years?* This field is required.

YESNO

11

Do you currently have an attorney representing you for your Social Security claim?* This field is required.

YESNO

12

Have you applied, or would you like to apply, for TDIU VA Compensation?* This field is required.(TDIU: Total Disability Rating based on Individual Unemployability)

YESNO

13

You do not need to apply for TDIU or have a service connected disability rating to receive SSDI. Please complete the next few questions to see if we can help you.

14

Do you think your medical condition(s) prevent you from earning wages more than $1,550 per month?

YESNO

15

Would you like us to help with your SSDI claim?

YESNO

16

What is your email?* This field is required.

example@example.com

17

What is the best phone number to reach you?* This field is required.Cell phone is the preferred method of contact.

18

Denial Message

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We are sorry that we cannot assist you.

{denialMessage}

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This does not impact your Veterans' Disability Compensation claim.

You should contact your Warrior Canine Connection representative to discuss your current VA disability claim or to file a new VA disability claim.

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Check the box below.* This field is required.By submitting this form I give express consent that this serves as my electronic signature to be called, text or emailed regarding a free consultation to determine if Veterans Help Group can help me with a Social Security Disability and/or Veteran's Disability claim. Standard cellular, message and data rates will apply and the caller may utilize an automated dialing system. Message frequency varies. For text reply HELP for help or STOP to cancel. I waive all federal and state no-call registry protections. I understand my consent does not require me to purchase anything and my number will not be stored or called for any other purpose. Consent is not a condition of representation. View our Privacy Policy and SMS Terms of Service