Environmental Litigation GroupA Professional Corporation · Est. 1990

VA Disability Claim Application Form

Free, confidential case evaluation. No fee unless we recover for you.

Were you honorably discharged from the Military?
Have you applied for disability benefits with VA?
Has your VA disability claim been denied in the past 12 months?
Has your previous claim been granted?
Did you sustain an injury while in the military?
Are you having medical issues you feel are related to your military service?
Did you receive medical treatment while in the military?
Did you serve outside the United States?
Did you ever smoked tobacco products?
Have you ever been represented by an attorney for a VA appeal before?
Do you have an official withdrawal letter from that attorney?
Does it mention a fee waiver?
Can you send us a copy of the Fee Waiver?
Do you have anyone else to add as a contact for your Case Review?
Do you have a diagnosis for all conditions to appeal?
Have you ever been diagnosed with any type of cancer at any point during your life?
Do you currently have a rating with VA?
Have you ever filed for the PACT Act before?

I declare under penalty of perjury that all information provided on this form is true and correct to the best of my knowledge.

Disclaimer: The use of the Internet, this website form, or email as means of contacting this firm or any individual attorney of this firm will not establish an attorney‐client relationship, thus do not use a website form or email to submit confidential or time‐sensitive information. Whether you are a potential or existing client of the firm, ELG cannot represent you on any new matter until the firm has made a determination that there is no conflict of interest and that it is willing and otherwise able to accept the new engagement. Unless and until (a) ELG has informed you it is willing and able to accept your new matter and (b) you have signed a retainer agreement provided by ELG outlining the terms of the engagement, do not send the firm any information or documents that you consider private or confidential.