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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.

DISABILITY PRE-SCREENING QUESTIONNAIRE

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

If YES list the date submitted and details of the claim below

How much do you currently receive in VA Disability Pay?

Do you receive any type of Separation / Severance / Retired Pay?

Yes No

If YES, list amount and type (if known)

What type of medical insurance do you have?

How did you find us?

What is the date you prefer for us to call you back?

Preferred time

Get Started

Disability Pre-screening Questionnaire

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)