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Your information

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Have you already applied for Social Security Disability benefits?

A

Yes, denied

B

Yes, pending

C

No

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Which of the following describes how much you have worked

A

I have worked in MOST of the last 10 years

B

I have worked in SOME of the last 10 years

C

I have worked in NONE of the last 10 years

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I agree to be contacted by phone or email regarding my disability claim.

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