Fillable PLEASE PRINT IMPORTANT! Please complete. I. Personal Information (Grossman Law Firm LLC.)

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Page | 1
PLEASE PRINT
How did you hear about our office? ____________________________
IMPORTANT! Please complete.
I. Personal Information
1. Name: _____________________________
2. DOB: __________ Age: _____
3. Social Security Number: _________________
4. Address:_________________________________________________
Street Number City, State Zip
5. Telephone Number(s): Main/Best Contact: ___________________
Alternate Contact: ___________________
E-mail address: ___________________
6. Are you currently in Bankruptcy? NO YES If “yes”, please give the name
and address of your Bankruptcy Attorney: _______________________________
____________________________________________________________
Please give your Bankruptcy Case Number: __________________________
7. Are you currently, or have you ever drawn Worker’s Compensation due to a work
related injury? NO YES If “yes”, please give the dates: _________________
(If you are currently drawing Worker’s Compensation please provide us with a copy of
your settlement papers).
8. Are you currently drawing Unemployment? NO YES Amount: $____
per week/month
9. Have you ever drawn any type of Social Security benefits prior to this
application? NO YES If “yes”, please explain why your benefits were terminated.
10.Are you currently drawing short term or long term disability? NO YES
(If you are currently drawing short or long term disability please provide us with
documentation showing when you began receiving benefits and for how long they are
expected to last).
11. Have you ever served in the United States Military? NO YES
12. Are you currently receiving Veteran’s Disability Benefits? NO YES
13. Are you currently working? NO YES
●
●
Page | 2
14. Do you have medical insurance? NO YES
15. Do you have Medicaid? NO YES
16. Are you currently drawing Social Security Retirement benefits? NO YES
II. Alternate Contact Person-Relative or Friend
1. Name: _____________________________
2. Relationship: _______________
3. Address:_____________________________________________
Street Number City, State Zip
4. Telephone Number: ______________
III. Work History-Please give your last 15 years of employment
Employer Job Description Dates Worked
Why are you no longer able to perform these jobs? _________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
IV. Education
1. What is the last grade that you completed (if you started a grade but did not
finish, please indicate the last grade you completed). _________
2. If you dropped out of school, please explain why: ______________________
3. If you did not graduate high school, did you obtain a GED? NO YES
Page | 3
4. Did you take any type of special education classes? NO YES
If yes, in what grade were you placed in special education classes? ________
5. Are you able to read and write more than just your name and other simple three
to five letter words? NO YES
6. Are you able to perform complex math? NO YES
7. Did you earn a college degree? NO YES
8. If “yes”, please indicate the degree that you earned. ___________________
9. Have you attended any type of vocational rehabilitation? NO YES
If yes, where at and during what years? ____________________________
V. Information About Your Condition(s)
1. Please list your condition(s):
A. __________________ B.__________________ C. _________________
D. __________________ E. _________________ F. _________________
G. __________________ H. _________________ I. ________________
2. Is your condition(s) related to an injury, i.e. car accident, slip and fall, etc.?____
If “yes”, please describe the event that led to your injury. _____________________
What year did this event take place? ___________
VI. Medical Treatment
1. Please list any doctors that you have EVER seen for your condition(s).
Doctor Name Doctor Type City and State of First Last Next
Office Location Visit Visit Visit
(DO NOT LEAVE BLANK)
Page | 4
2. Have any of the doctors listed above told you to stop working? If yes, which
doctors? _________________________________________________
3. If you are no longer seeing your doctor due to a lack of finances and/or health
insurance, do you go to the emergency department for your health problems? If
yes, which emergency department(s) do you typically go to? ______________
_______________________________________________________
_______________________________________________________
_______________________________________________________
4. When was the last time that you went to the emergency room and/or urgent care
for your condition(s)? _______________________________________
5. Are you prescribed any assistive devices by your doctor; i.e., cane, brace, etc.?
NO YES If yes, what type of device? ______________________
6. Please list all medications that you are CURRENTLY taking.
Name of Medication Who Prescribed It Why you take it Side Effects YOU have
Page | 5
7. Please list any tests that you have EVER had (X-ray/MRI/EMG/Colonoscopy)
Name of Test Who Sent You For Test Where was the test done Date of test
8. Please list any surgery that you have EVER had for your condition(s).
Name of Surgery Date of Surgery Reason for Surgery Surgeon/Place
of Surgery
9. Are you CURRENTLY seeing a doctor/hospital for your medical condition(s)?
NO YES If “no”, please explain why you are not currently seeing a doctor.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Page | 6
10. In your opinion, which of your conditions most limits your ability to perform any
type of work? __________________________________________________
11. Please explain how your conditions affect your ability to perform the following:
• Bathing: _________________________________________________
• Dressing: _________________________________________________
• Fixing Food: ______________________________________________
• Household chores: __________________________________________
• Outdoor chores: ____________________________________________
• Socializing: _______________________________________________
• Driving: _________________________________________________
• Shopping: ________________________________________________
VIII. CRIMINAL HISTORY
1. Have you EVER been convicted of a crime? NO YES If “yes”, please
explain. __________________________________________________
__________________________________________________________
__________________________________________________________
2. Have you EVER had a problem with illicit drug or alcohol use or abuse?
NO YES If “yes”, please explain. ___________________________
__________________________________________________________
__________________________________________________________
3. Have you EVER been admitted into a drug or alcohol rehabilitation program?
NO YES If “yes”, please explain. ___________________________
__________________________________________________________
Page | 7
IX. SOCIAL NETWORKING
Please check the social networking application that you participate in:
Facebook
Twitter
Instagram
Other: _____________________
VIII. OATH OF TRUTH
I , _________________________, hereby swear that the information
provided on the above information sheet is the true and correct to the best of my
knowledge. I understand and agree that should I knowingly provide false information
to Grossman Law Firm, LLC, should Grossman Law Firm, LLC choose to represent me,
the same will be grounds for immediate termination.
___________________ ______
Claimant Signature Date
Please answer the following questions
1. Date you filed your Social Security Disability Application? _____________
2. Since filing your application has your condition(s) become better, worse or
stayed the same? Please explain.
3. Since filing your application do you have any new conditions or any conditions
you forgot to include initially? Please explain
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Completed 29 March 2021

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