Veterans Disability Evaluation Form

Please complete our FREE Veterans Disability Form. One of our representatives will contact you shortly.

Bold labels and This graphic indicates a required field. indicate required information.

First Name:*

Last Name:*

Date of Birth

Email:* (Please enter a valid email address)

Street Address:

City:

State:

ZIP (5 digits)

Telephone Number:

Are you currently receiving service-connected disability benefits?*

Yes

No

If applicable, what is your combined rating?

Did you receive an initial decision?

Yes

No

Did you file a Notice of Disagreement?

Yes

No

If applicable, Date Notice of Disagreement was filed

Are you currently working?

Yes

No

If applicable, is it due to your service-connected disability?

Yes

No

If applicable, Date last worked

Are you receiving Social Security Disability or Supplemental Security Income benefits?

Yes

No

Are you receiving service-connected pension?

Yes

No

What service connected disabilities are you claiming?
(Maximum length: 500 characters.)

How Can We help You?
How would you like us to assist you with your claim?

The information you obtain at this site is not, nor is it intended to be, legal advice. We invite you to contact us and welcome your calls, letters and electronic mail.

The Rep for Vets®

5325 Primrose Lake Circle
Suite B
Tampa, FL 33647
Office: 813-870-1738
Fax: 813-874-2073