Social Security Form

Date
First Name
Last Name
Birthdate (age)
Address
City
State
Zip Code
Phone (home)
Phone (work)
Phone (message)
Social Security #
Spouse Name
Children names and ages
Date of injury
Claim Number
Who referred you to our office?
Where did you last work?
Why did you stop working?
When did you apply for Social Security Disability?
Indicate last status of claim: Date 1st application denied:
Date request for reconsideration filed:
Date reconsideration denied:
Date request for hearing filed:
Date hearing scheduled:
Judge assigned:
Who are your doctors:
What treatment have you received:
Highest grade completed:
Job held as of last date of work:
Wage of last job:
Jobs held 15 years prior to disability:
Do you have current workers compensation claim? Claim No.:
Status (time loss rate):
Are you represented in that case? (Attorney):
Any prior industrial injuries? (Claim numbers):
Have you drawn public assistance or unemployment since you stopped working? (Details):
Name of DSHS caseworker/telephone number:
Have you applied for Social Security Disability before? (when; results)?
Have you been represented by other attorneys in this claim (who)?
Other information which would assist us in evaluating your claim:

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