Form – SSDI Assist

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your answers helped us determined that we can’t help you at this time.

Do you expect to be out of work for at least a year?

Do you expect to be out of work for at least a xxyear?

YES

Have you worked for 5 of the last 10 years?

YES

Are you currently receiving Social Security Disability benefits?

YES

Is an attorney helping with your case?

YES

Are you receiving treatment from a Medical Professional?

YES

What is Your Name?

First Name *

Last Name *

✅ Your Information is safe & secure

How old are you?

What is Your Address?

Address *

Unit

City *

State *

ZIP *

✅ Insurance companies require this in order to provide an accurate quote.

What is Your Email?

✅ No Spam Guaranteed

Last Step.

What is Your Phone Number?

Phone Number *

By clicking “Submit” below I am providing my ESIGN signature and express written consent agreement to permit Citizens Disability, LLC to contact me at the number and/or email provided above for marketing purposes regarding Citizens Disability services, including a disability claim, benefits optimization, Medicare, and/or pharmacy services, and customer care messages, such as information and reminders regarding your disability claim. I understand that these calls and/or SMS/MMS messages include those using automated technology, AI texting, AI generative voice, and artificial voice messages. I confirm that the phone number above is accurate, and I am the regular user of that phone. I agree to Citizens Disability’s Terms and Conditions and Privacy Policy. I also agree to the Terms and Conditions and Privacy Policy of this website. For SMS messages campaigns, text “STOP” to stop and “HELP” for help. Message frequency may vary. Msg & data rates may apply. I acknowledge that my consent is not required to obtain any good or service, and to contact Citizens Disability without providing consent I can call 888-882-0424.

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