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Disability Pre-screening Questionnaire

Disclaimer: Please do not include any information that could be deemed sensitive, such as: SSN, DOB, insurance, etc.

In order to best serve you, and know if you’re a good fit for submitting a claim, Vital Veterans Consultants needs to collect the following information. Your accurate and thorough answers are needed to properly pre-screen your eligibility. Rest assured your information is strictly confidential and safe with us.

Note: this questionnaire is expected to take 20 minutes to complete. Be sure to hit “SUBMIT FORM” at the bottom of the form or we will not receive your information.

Your Details

First Name:

Last Name:

Email Address:

Phone Number:

Military Service and Current VA Service Connected Disabilities

What branch of the Military did you serve?

What was your military service status?

Service Start Date

Date of Separation

Place of Separation

Are you a Combat Veteran?

Yes No

How many years did you serve on active duty?

Do you CURRENTLY have a VA Service Connection disability rated at 0% or higher that negatively impacts your life?

Yes No

If YES list current conditions and percentages

Do you currently have any pending claims / appeals in the system?

Yes No

How did you find us?

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Disability Pre-screening Questionnaire

Your Details

Military Service and Current VA Service Connected Disabilities

That's it! Thank you for your information. We'll be in touch soon.

Veteran owned consultant company out of Jacksonville, FL.

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1.855.888.VETS (8387)