Herren Law has been representing disabled clients since 1992. Since that time we have helped over 4,000 people with their disability claims. We are often the difference between success and failure. The sooner you get help the better and the more likely that you will succeed.

All fields marked with an asterisk (*) are required. All other fields are optional but will assist us in evaluating your specific claim.

Please provide the following contact information:

Name *
Street Address
Address (cont.)
City *
State/Province *
Zip/Postal Code
Home Phone
E-mail *

Date of Birth

"mm/dd/yy"

Choose one of the following options:

Single
Married
Widow/Widower

Have you applied for Social Security Disability within the last 24 months?

Yes
No

Are you currently receiving disability benefits?

Yes
No

Do you have a pending claim?

Yes
No

Description of disability:

Are you currently working?

Yes
No
Part-time

If not, when did you become unable to work?

-- mm/dd/yy

Enter the date of your last employment:

-- mm/dd/yy

What was your job?

General comments we should know:

How did you find us (check all that apply)?

TV Advertisement
Friend/Referral
Search Engine
Website Link
Other

I understand that submitting this form does not create an attorney-client relationship.