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Veterans Administration Disability Claim Application Form
First Name
Last Name
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Dates of Active Duty
Branch of Military
Military Job Title(s)
Were you honorably discharged from the Military?
Yes
No
Where were you stationed: (please provide names of all military bases, ships, etc.)
Have you applied for disability benefits with VA?
Yes
No
Has your VA disability claim been denied in the past 12 months?
Yes
No
Has your previous claim been granted?
Yes
No
What percent rate?
Did you sustain an injury while in the military?
Yes
No
What was the injury you sustained and when did it occur?
Are you having medical issues you feel are related to your military service?
Yes
No
Please describe service related medical issues and estimated diagnosis dates
Did you receive medical treatment while in the military?
Yes
No
When and where were you treated?
Did you serve outside the United States?
Yes
No
Where?
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