Ready for help? Fill out this form and we’ll let you know if we can help you. All fields MUST be filled in. Name*Email* Phone*What can we help you with?*What can we help you with?*I'm an existing client.Workers' CompSocial SecurityVeterans DisabilityZip Code*Date of Injury*Body part(s) injured*Select all that apply. Head Neck Back Shoulder Arm Hand Finger Leg Knee Foot Death Other Have you injured these body parts before?*YesNoIf yes, please describe the previous injury:Have you filed a claim with the Division of Workers' Compensation?*YesNoAre you receiving workers' comp benefits checks?*YesNoWas receiving checks, but they've stopped.Are your medical bills getting paid?*YesNoBills were getting paid, but they've stopped.Who is the insurance carrier?*Have you received an admission of liability?*YesNoUnsureIf yes, what type?General Admission (or)Final AdmissionDate of AdmissionHas your doctor put you at Maximum Medical Improvement?*YesNoHave you had surgery?*YesNoIf yes, please describe the surgery:What medical treatment are you currently getting?*Status of your case*Status of your case*I have not applied yet.I have been denied.I've had a hearing & was denied by a judge.Date of denial* Why did Social Security deny you?*Why did Social Security deny you?*I do not meet the rules for disability.I can do work that I've done before.I can do other work.My condition should improve within 12 months.My income (or my spouse's) is too high.I'm uninsured or don't meet the rules for disability as of a certain date.Date you were last insured** Age*Date last worked*What are your disabling conditions?*Are you currently seeing a doctor?*YesNoDo you live in Colorado?*YesNoWe only accept cases for veterans who currently reside in the state of Colorado.Case type*Select all that apply. Mental illness: seeking service-connection Mental illness: seeking an increase in my rating TDIU/Unemployability Pension (due to unemployability) Other We only take cases with claims for TDIU or mental illness. If you don’t have a claim for TDIU or mental illness, please go to https://vetadvocates.org/ for a list of attorneys who may be able to help you.*Have you received a rating decision or statement of the case?*Rating DecisionStatement of the CaseDate of rating decision* Did you appeal the Rating Decision?YesNoDate of Statement of the Case* Did you appeal the Statement of the Case?*YesNoWhat are your service connected conditions?*Why are you contacting an attorney?*Please add any additional information that you feel will help us better evaluate your case.Your message.PhoneThis field is for validation purposes and should be left unchanged.