DO I HAVE A SOCIAL SECURITY CLAIM

DO I HAVE A SOCIAL SECURITY CLAIM?

If you believe you have a social security disability claim, and would like to consult with Richard; or you have a pending claim, and need representation, please feel free to complete this questionnaire regarding your claim. Richard, or one of his trained paralegals, will get back to you as soon as possible to discuss your case.

First Name
Middle Name
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Daytime Phone	() -
Evening Phone	() -
E-mail Address
Are you applying for Social Security Disability, SSI or both?
Have you applied already?
Have you received an Initial Determinination already?
If so, what was the date of the Determination?
Have you filed a Request for Hearing before and ALJ?
If so, has an Hearing been Schduled already? With Which ALJ?
Date of Birth?
Highest Grade of Education you completed?
What was the date that you last worked?
What date of onset did you use on your application ?
Did you continue to work in a modified or part time capacity after your date of onset?
Name of Last Employer?
Job Title?
Briefly describe your job duties?
What was the Heaviest weight you would lift at wok?
What was the "average" weight you would lift every day at work?
Describe your injuries or disabling conditions?
Were you ever hospitalized as a result of any of these conditions? If so where and for how long?
Names of Doctors you have treated with for these conditions?
What type of treatment have you received for these conditions, i.e.; surgery, therapy, medications etc.?
Any additional relevant information?
Any additonal comments or questions?

Law Offices of Richard Jaffe, Esq., assist clients with Workers' Compensation and Social Security Disability matters in Philadelphia, PA as well as the cities of Lansdowne, Upper Darby, Darby, Sharon Hill, Drexel Hill, Folcroft, Clifton Heights, Glenolden, Havertown, Norwood, Holmes, Prospect Park, Essington, Springfield, Media, Folsom, Ridley Park, Bryn Mawr and Swarthmore, in Delaware County and Philadelphia County.