Increased Rating Statement Form

Increased Rating Statement Form

Please complete a statement form for EACH claim you intend to pursue that you are already service-connected for. If you have any questions, please contact your case manager for more information.
Name*

First NameLast Name
Phone Number*
Please enter your phone number
Email
example@example.com
Who asked you to complete this form?*
What device are you using to complete this form?*

Other
List ALL symptoms you currently experience:*
Please use specific details
Have you recently gone to a doctor or received any kind of treatment for this condition?*

Interference with Employment
When was your last Comp & Pen Exam for your {whichMedical}?*
HOW have your symptoms have gotten worse since your last Comp & Pen Exam?*
Have you developed any new symptoms? Has your medication dosage increased?
What is your current employment status?*
Date Last Worked*

MonthDayYear
Date
How have your symptoms have impacted your ability to WORK?*

Review and Submit
Is there anything else you would like to add to your statement?
Upload any additional information here

Cancelof
We use a secure AI tool to help draft well-written and organized statements based on your responses and the information you've provided. This tool assists us in creating your statement and developing evidence for your case.*

I understand that this information may be put into a secure AI tool to assist with the development of evidence in my case.
Should be Empty:

THIS STATEMENT IS ABOUT ...