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New York Personal Injury Attorneys
New York Personal Injury Lawyers Providing Personal Injury Lawyers in New York State
Airplane Crashes
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Car Accidents
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Plane Accident Lawyers
Premises Liability
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Psychiatric Malpractice
ReNu Contact Lens Alert
Sexual Assault
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Your Current Age:

Work History:
Are you presently working? Yes   No
*If Yes, please note, we cannot assist you if you are working
When did you stop working?
In the last 7 years, please tell us about your work activity:

Year Full Year Part of the year Did not work at all
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2003

Social Security Claim Status:

Have you applied for 
Social Security Disability 
(SSDI) in the last 18 Months?
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If yes, is the 
claim still Pending?

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If yes, at what level?

Was your claim denied?

Yes   No   Not Sure
If yes, at what level?

Give us the approximate 
date of your last denial:

 

Please describe your disability:
Please tell us some of your
physical and mental limitations:

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

Is a doctor currently treating you?

Yes    No
If no, why not?
Is the injury work-related? Yes    No
If Yes, did you file a Workers 
Compensation Claim?
Yes    No
Are you receiving or have your 
Received Workers Compensation?
Yes    No
Do you have an attorney presently 
assisting you in a Social Security 
Disability (SSDI) claim?
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If Yes, why are you seeking our assistance?
Please list the medications you are taking:


Are you receiving any other types of benefits
listed below? *Please check all that apply:

Long Term Disability
Early Retirement From Social Security
Widow's Benefits From Social Security
Personal Injury Settlement
Medical Malpractice Settlement
Other


How did you become disabled?
*Please check all that apply

Natural Causes
Sickness/Illness/Disease
Medical Malpractice
Car Accident
Injury or Accident
Medication or Product
Other

If you chose "Medical Malpractice," "Car Accident,"
"Injury or Accident," "Medication or Product," or "Other"

Date of incident:   *
City where incident occured: *
State where incident occured: *
What was the date of the incident?  
What city did the incident occur in?
What State did the incident occur in?   


Please tell us what happened. Be sure to include
all the facts including who was at fault and why:*


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