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Mon–Fri: 9:00 AM – 4:30 PM | Sat–Sun: Closed
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Gumps Victor
Alpha Compensation
Welcome
Request Consultation
Learn
Legal Fees And Services
FAQ’s
VA Disability Claim Appeal Process
Veterans Disability
Covid-19
Individual Unemployment Eligibility
Why should I pay when VSOs do it for free?
Service Connected Compensation
Privacy Policy
Our Advantage
Help with VA Claims
Gump Talks VA Disability
Contact
Meet The Team
Locations
Conroe, Texas (Main Office)
Greeneville, Tennessee
Parkersburg, West Virginia
Phoenix, Arizona
Welcome
Request Consultation
Learn
Legal Fees And Services
FAQ’s
VA Disability Claim Appeal Process
Veterans Disability
Covid-19
Individual Unemployment Eligibility
Why should I pay when VSOs do it for free?
Service Connected Compensation
Privacy Policy
Our Advantage
Help with VA Claims
Gump Talks VA Disability
Contact
Meet The Team
Locations
Conroe, Texas (Main Office)
Greeneville, Tennessee
Parkersburg, West Virginia
Phoenix, Arizona
Veteran Intake Questionnaire
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1
SECTION 1
2
SECTION 2
3
SECTION 3
4
SECTION 4
5
SECTION 5
6
SECTION 6
SECTION 1 – Veteran Information
Veteran Legal Name:
*
Sex
--- Select Choice ---
Male
Female
Date of Birth
Phone
Email
*
Address
Address Line 1
City
State / Province / Region
Postal Code
VA File Number/SSN
*
Next
SECTION 2 – Military Service
Branch(es)
*
Service Dates From
Service Dates To
Component
Active
Guard
Reserve
Discharge
Honorable
General
OTH
Dishonorable
Medical
Unknown
MOS
*
Rank
*
Combat Zone?
Yes
No
Unsure
Combat Pay?
Yes
No
Unsure
Deployed?
Yes
No
Known Exposures
Burn Pits
Agent Orange
PFAS
Asbestos
Radiation
Noise
Chemicals
Other
If yes, where
Other
Previous
Next
SECTION 3 – VA Claim History
Previously filed a VA claim?
Yes
No
Current combined rating %
*
Service-connected conditions and ratings
*
Pending claims?
Yes
No
Previously denied conditions:
*
Last Rating Decision Date
*
Copy of decision available?
Yes
No
Current representation by attorney, claims agent, or VSO?
Yes
No
Unsure
Do you currently have a signed fee agreement with another attorney or accredited claims agent?
Yes
No
Unsure
If yes, name of attorney/agent/law firm
Previous
Next
SECTION 4 – New Claim Intent
Conditions you are seeking service connection for
*
Diagnosis
*
--- Select Choice ---
Yes
No
Currently receiving treatment?
*
--- Select Choice ---
Yes
No
In-service event/injury
*
Current medications
*
Previous
Next
SECTION 5 – Employment & Family
Employment
*
--- Select Choice ---
Full-time
Part-time
Unemployed
Retired
Occupation
*
Monthly income (if part-time) $
*
Unemployed due to disabilities?
Yes
No
Last day worked
*
Retirement date
Retired due to disabilities?
*
Yes
No
Marital Status:
*
--- Select Choice ---
Single
Married
Divorced
Widowed
Dependents?
*
--- Select Choice ---
Yes
No
Previous
Next
SECTION 6 – Medical Treatment
Treatment
*
--- Select Choice ---
VA
Private
Both
Private provider names/conditions
*
Has VA received private records?
*
Yes
Np
Additional comments
Submit
