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Social Security Disability

Social Security Disability Lawyers

Serving Hartford, Waterbury, New Haven and Surrounding Areas

Call us today at 1-800-TRANTOLO (1-800-872-6865) or 860-522-9248.

Your Privacy: Any information provided to us over the phone or through the form below is stricltly confidential and cannot be shared with anyone.

If you prefer, you can fill out this form so we can evaluate your case before we contact you.

Title:* First Name:* MI Last Name:*

Email Address:* Home Phone: *
(ex. janesmyth@domain.com)

Work Phone: 		(ex. 555-505-5555)

Cell Phone:
(ex. 555-505-5555)

Address: 		(ex. 555-505-5555)

City:

State:
Zip:

 
(ex. 06109)
Date of Birth:    
Marital Status: 

If you are completing this form for another person would you please enter your name and phone number
Your Name:  
Your Phone: 

Claim Status:
Have not applied
Have applied but have not received a determination
Have applied and been denied
At original claim
At reconsideration
At hearing stage

How many times have you previously filed?
1 2
 3
 4
 5 or more


If denied, what level?
Initial
Reconsideration
Administrative Law Judge
Appeals Council

Most recently denied:    

Date you became disabled:    

Have you worked 5 out of the last 10 years?  Yes    No

Last date you worked:    

Are you working?  Yes    No

Disability: 

Physical/Mental Limitations:


Conditions & Symptoms:
Back Injury Heart Problems
Neck Injury Poor Circulation
Hip Injury Nerve Problems
Knee Injury HIV
Foot Problems Hepatitis
Asthma Mental Illness
Bronchitis Anxiety Disorder
Sleeping Problems Panic Attacks
Depression Disorder Bi-Polar
Epilepsy Multiple Sclerosis
ADD Concentration Problems
ADHD Memory Problems


Are you being treated?  Yes    No

Do you have an attorney?  Yes    No

Is the injury work related?  Yes    No

Medications:


Other Claims?
Workers Comp
Long Term Disability
Personal Injury
Medical Malpractice
Other

Case Information:

Case Description:


Comments/Additional Information:


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I understand that by filling out this free consultation form I am not forming an attorney client relationship. I understand that I may only retain an attorney by entering into a fee agreement and that by submitting this form, I am not entering into a fee agreement.
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I understand that the above does not constitute a request for legal advice. I agree that any information that I will receive in response to the above question is general information and I will not be charged for the response to this email question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. I agree that if this matter requires advice regarding my home state, local counsel may be contacted for referral of this matter and I hereby authorize local counsel to initiate direct contact with me, by phone, mail or email. I understand that this email is not secure and thus I am forming only a semi-confidential relationship.
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Connecticut Personal Injury Lawyers Serving Hartford, Waterbury, Bridgeport,
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Connecticut Car Accident Lawyers Disclaimer: The information presented on this website for Trantolo & Trantolo Attorneys at Law serving Harford, Waterbury, New Haven and Bridgeport, Connecticut should not be taken as formal legal advice including reference to Auto Accidents, Boating Accidents, Cerebral Palsy,Product Liability, Medical Malpractice, Motorcycle Accidents, Nursing Home Negligence, Personal Injury, Truck Accidents, Hartford Personal Injury Lawyers and Waterbury CT Attorneys. If you or a loved one have been injured, contact us to schedule a consultation with a Connecticut personal injury lawyer to see if you have a claim.