Is a Disability Keeping You from Working? Get a FREE Evaluation and Get the Benefits You Deserve! Applicant Info Qualify Results American Bar Association National Association of Disability Representatives What health condition prevents you from working? --Please Select-- Cancer Amputation Brain Injury Multiple Sclerosis Muscular Dystrophy Stroke Organ Transplant Joint Replacement Anxiety Diabetes Depression Fibromyalgia/pain Diagnosed Gout Migraines Obesity High Blood Pressure Other None First Name Last Name Street Address Zip Code State City Email Phone - - Date of Birth mm 01 02 03 04 05 06 07 08 09 10 11 12 / dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / yyyy 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Secure Evaluation Do you expect to be out of work for at least a year? Yes No Since 2013 have you worked at least 5 years? Yes No Are you married? Yes No Highest education completed Please select 6th Grade or Less 7th-11th Grade High School Graduate College Degree or Certification Are you currently receiving Social Security Disability benefits? Yes No Is an attorney helping you with your case? Yes No Are you receiving treatment from a Doctor? Yes No Describe your disability with at least 5 characters Wait! Your application is not complete. You stated that you are already working with an attorney. Unfortunately we cannot assist you if you already have an attorney helping you with your Social Security Disability Benefits application. Please select an option below: Yes, please have a new representative contact me. No, I do not need a new evaluation. I am currently working with a lawyer on my Social Security Disability case. Secure Evaluation Wait! Your application is not complete. You stated that you are not receiving treatment from a Doctor. Unfortunately we cannot assist you if you are not receiving medical treatment for your disability. Please select an option below: Yes, I have received medical treatment in the last year for my disability. Please have a representative contact me. No, I am not receiving medical treatment. Secure Evaluation Secure Evaluation By clicking 'Secure Evaluation' and submitting my request, I confirm that I have read and agree to the privacy policy of this site and that I consent to receive emails, phone calls and/or text message offers and communications from American Disability Network and its network of lawyers and advocates at any telephone number or email address provided by me, including my wireless number, if provided. I understand there may be a charge by my wireless carrier for such communications. I understand these communications may be generated using an autodialer and may contain pre-recorded messages and that consent is not required to utilize American Disability Network’s services. I understand that this authorization overrides any previous registrations on a federal or state Do Not Call registry. I also agree to receive relevant email from NationalSSD and Fortifynance.