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 Rep for Vets®

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