Application for Representation – Disability Pension Attorney

Please complete this form as fully as possible. All information is kept strictly confidential. Submission of this form does not create an attorney-client relationship.

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Street Address

City

State

Zip Code

Employment Information

Employer / Agency *

Title / Rank

Pension System

Years of Service

Are you currently working?

Disability / Injury Information

Type of Claim

Describe Your Injury or Condition *

Have you already filed a disability retirement application?

Additional Information

How Did You Hear About Us?

Referral Source

Your information will be sent securely to our office. We will review your submission and contact you promptly.