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In order to best serve you, and know if you’re a good fit for submitting a claim, we need to collect the following information. Your accurate and thorough answers are needed to properly pre-screen your eligibility. Rest assured your information is strictly confidential and safe with us. Note: this questionnaire is expected to take 20 minutes to complete. Be sure to hit “send” at the bottom of the form or we will not receive your information.

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Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone

Military Service and Current VA Service Connected Disabilities

What branch of military did you serve?*

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What branch of military did you serve?

What was you military service status?

Service Start Date

Date of Separation

Are you a Combat Veteran?

Yes

How many years did you serve Active Duty?

Do you CURRENTLY have a VA Service Connection disability rated at 0% or higher that negatively impacts your life?

Yes

What is your current percentage?*

If "Yes" list current conditions and percentages

Do you currently have any pending claims or appeals in the VA system?

Yes

If "Yes" list the date submitted and details of the claim below:

How much do you currently receive in VA Disability Pay?

Do you receive any type of Separation / Severance / Retired Pay?

Yes

If "Yes" list amount and type (if known)

How did you find us?

Relevant Social, Family, and Martial History

What is your current marital status?

Do you have children? If so, how many do you have?

How did you hear about us?

https://veteran-alliance.com/get-started/

This field is for validation purposes and should be left unchanged.

Get Started

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Military Service and Current VA Service Connected Disabilities

Relevant Social, Family, and Martial History

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