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By submitting this form, you are authorizing Bradshaw Social Security Law P.C. to contact you. This firm does not guarantee the security or receipt of information submitted through this site. No attorney-client relationship is formed upon submission of this form. Time-sensitive information should not be sent using this form; please contact our office by telephone.

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Name:

 
Email Address:

Mailing Address:

 

Phone Number:

 

Age:

 

Maritial Status:

 

Last day of work:

 

Date you became physically or mentally unable to work full time:






 


Stage of claim for benefits:



 

 

If other, please list the status of your claim here:


What is the date stamped on your most recent denial:



 

Ever filed a workers' compensation claim?

 


What physical or mental impairments do you have, and how do they limit your ability to work?


 

Were you referred to us by an attorney?


 


If so, please give the attorney's name, city and state:





 

If not, how did you hear about about us?


 

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Bradshaw Social Security Law P.C.   -|-   454 West Jackson Street   -|-   Woodstock, IL 60098
Phone: TOLL-FREE 1-877-SSD-ATTY (1-877-773-2889)
Alternate Phone: 815-206-2908   -|-   Fax: 877-773-9889