VA New Claim Questionnaire
You have contacted us about filing a claim with the VA for a new disability. Please complete the following questionnaire to assist us with preparing your claim. We will be in contact once you complete the questionnaire.
Name
First Name
Last Name
What disability or medical condition do you want to file for?
*
Have you been diagnosed with the disability or medical condition?
*
YES
NO
What is your theory of service connection?
*
Direct service connection - condition began in or was caused by service.
Secondary service connection - condition due to another service connected condition.
Direct Service Connection - Explain how your condition began in or was caused by your service.
Do you have evidence showing the disability or medical condition began in service?
YES
NO
If yes, what is the evidence?
Secondary service connection - what service connected condition(s) caused the secondary condition?
Explain how the service connected condition(s) caused the secondary condition.
Thank you. We will file an INTENT TO FILE to hold a place for this claim and will be in touch soon.
Submit
Should be Empty: