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Step 1 of 2 50% Practice Area*AutoBankruptcyChild CustodyChild SupportCriminal DefenseDUIDivorceDivorce MediationEmploymentExpungementFamilyImmigrationLong Term DisabilityMed MalPersonal InjurySSDITraffic TicketsTrucking AccidentVeterans DisabilityWorkers CompensationWrongful DeathHow old are you?*181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465Do you expect to be out of work for at least a year due to your health?*YesNoHave you been treated by a doctor, hospital, or clinic in the last year?*YesNoHave you had a full time job within the past 5 years?*YesNoDo you already receive Social Security benefits?*YesNoHave you hired an advocate or attorney to help get benefits?*YesNoWhat is your total debt?*Less than $5k$5k-10k$10k-20k$20k-50kMore than $50kWhat is your total monthly income?*Less than $1k$1k-5k$5k-10k$10k-15kMore than $15kDo You Own Real Estate?*YesNoWhat is the estimated value of your assets?*Less than $50k$50-$500k$500k-$1mMore than $1 millionTotal employees that work for the business*1-56-2021-5051-100101-500501-1,000>1,000The Employer is a*Sole proprietorship (mom and pop)PartnershipFranchisePrivately held companyPublic corporationGovernment AgencyDon't knowOf What Country Are You a Citizen?*AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChina, People's Republic ofColombiaComorosCongo (Congo â Kinshasa)Congo (Congo â Brazzaville)Costa RicaCote d'Ivoire (Ivory Coast)CroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea (North Korea)Korea (South Korea)KuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTimor-Leste (East Timor)TogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweHow will you pay legal fees if you hire a lawyer*CashCheckCredit CardFriendFamilyOther (specify below)Immigration Issue*CitizenshipPermanent VisaTemporary VisaOther (please describe below)The person with the immigration matter is*In the USA with proper documentationIn the USA without proper documentationNot in the USAIn deportation proceedingsOther (please describe below)Status of the Claim*No action taken yetDemand for compensation madeLawsuit filedOtherWhen Did the Incident Occur?*< 1 year ago1-3 years ago>3 years agoPrimary Injury*AnxietyBack or Neck PainBroken BonesCuts and BruisesHeadachesMemory LossLoss of LimbOther (Describe next)Cause of Injury*Traumatic Physical Injury (Accident)Repeated Trauma InjuryMental InjuryOccupational DiseaseNot SureDo You Have Children*YesNoN/AMarital Status*Unmarried, Living TogetherUnmarried, Do Not Live TogetherMarried, Living TogetherSeparatedDivorcedOtherHow will you pay legal fees if you hire a lawyer*CashCheckCredit CardFriendFamilyOther (specify below)How will you pay legal fees if you hire a lawyer*CashCheckCredit CardFriendFamilyOther (specify below)When did the charge occur?*Less than 1 Year Ago1-5 Years Ago6-10 Years AgoMore than 10 Years AgoWhat type of charge?*FelonyMisdemeanorJuvenileOtherYour Relationship to Child(ren)*FatherMotherGrandparentAunt/UncleOtherWith Whom Do the Children Currently Live?*MotherFatherGrandparentsOtherHow will you pay legal fees if you hire a lawyer*CashCheckCredit CardFriendFamilyOther (specify below)Who is the primary care-giver?*MotherFatherOtherYour Relationship to Child(ren)*FatherMotherGrandparentAunt/UncleOtherWith Whom Do the Children Currently Live?*MotherFatherGrandparentsOtherHow will you pay legal fees if you hire a lawyer*CashCheckCredit CardFriendFamilyOther (specify below)Who is the primary care-giver?*MotherFatherOtherDo You Have Children*YesNoN/AMarital Status*Unmarried, Living TogetherUnmarried, Do Not Live TogetherMarried, Living TogetherSeparatedDivorcedOtherDo You Have Children*YesNoN/AMarital Status*Unmarried, Living TogetherUnmarried, Do Not Live TogetherMarried, Living TogetherSeparatedDivorcedOtherHow will you pay legal fees if you hire a lawyer*CashCheckCredit CardFriendFamilyOther (specify below)Family Law Issue*AdoptionChild CustodyChild SupportDivorceDomestic ViolenceGuardianshipMarriage/PartnershipPaternityPremarital AgreementsSpousal SupportApplicant's Occupation*Applicant's Age (must be between 18 and 65)*181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465How did the applicant obtain the Long Term Disability policy?*EmployerSelfOtherHas the applicant previously applied for Long Term Disability benefits?*Yes, claim pendingYes, claim deniedNoHas the applicant ever received Long Term Disability benefits for this claim?*Yes, currently receivingYes, appealing a decision to stop payment of benefitsNoApplicant's monthly salary/pay when last at work*<$1,000$1,000 - $2,000$2,000 - $3,000$3,000 - $4,000$4,000 - $5,000$5,000 - $6,000$6,000 - $7,000$7,000 - $8,000$8,000 - $9,000$9,000 - $10,000>$10,000Type of Driver's License*PrivateCommercialTraffic Violations*DUI / DWISpeedingDisregarding a Stop SignDisregarding a Red LightDMV Letter About LicenseFailure to Appear in CourtLicense Suspended/RevokedMinor in Possession of AlcoholNo Child Safety SeatNo Liability InsuranceNo Seat BeltOpen Container of AlcoholRacingUnpaid Traffic TicketsWarrant Issued for ArrestOther ViolationDo You Have a Court Date*YesNoWas a Police Report Filed?*YesNoWhen Did the Incident Occur?*< 1 year ago1-3 years ago>3 years agoPrimary Injury*AnxietyBack or Neck PainBroken BonesCuts and BruisesHeadachesMemory LossLoss of LimbOther (Describe next)What is your relationship to the applicant?*Self, Active dutySelf, Active ReserveSelf, Discharged from active dutySelf, Discharged as reservistSurviving family memberOtherWas the applicant hurt while on duty or is the condition related to military service?*YesNoWhat service connected conditions does the applicant have? (select all that apply)*Has the applicant applied for VA disability compensation?*Yes, Claim filed and awaiting decisionYes, Claim deniedYes, Claim on appealYes, Claim approvedYes, Benefits awardedNo, Claim has not been filedCase Description* Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*CAPTCHA