Free Evaluation for Social Security Disability

WELCOME 90.7 KWMU LISTENERS!

If you have a disability and would like to see
if you qualify for Social Security disability
benefits, fill out the free evaluation below.
One of our representatives will contact you soon.

This information will be held strictly confidential.
If you'd rather speak with a representative, call 1-800-722-1286.

Name
Email
Street Address
City/State/Zip
Phone
Preferred Method of Contact	Phone E-Mail
Alternate Contact Name
Alternate Contact Phone
Date of Birth
General Medical Problems
Work History: Last 5 Years
Last Date Worked
Education
Tell us how your condition prevents you from working
Have you previously applied for Social Security disability benefits?	Yes No
If yes, please explain:
Is there anything else you would like us to know about your disability?

SSA Advantage and Advantage 2000 Consultants, Inc. are not government agencies and are not affiliated with the Social Security Administration or any other federal, state or local government entity.

Advantage 2000 Consultants, Inc. is a private non-attorney corporation providing Social Security disability representation services.

Advantage 2000 Consultants, Inc • 4121 Union Road Suite 216, Saint Louis, Missouri 63129
(800) 899-3433