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Intake & Eligibility Review Q&A

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Thank you for doing our Intake and Eligibility Review Q&A! The information you provide is and will remain confidential. CaseSix will never disclose, sell, or rent your information. Our servers are HIPPA compliant to protect your Personally Identifiable Information (PII).

For more information, please refer to our Disclaimer & Disclosure page.

Quick Heads-Up. The Q&A should only take 4 to 7 minutes to complete. Our Q&A is slightly more in-depth than others, and for a good reason. We’d rather ask you for a little extra (easy) information now and avoid the back-and-forth later.

Within our Q&A, you can upload copies of your VA Decision Letters, DD214, STRs, or whatever relevant information you feel will help us understand your situation. Or, you can wait until after we talk on the phone, and we’ll email you a Private Dropbox link afterward.

After you’re done, you’ll receive a copy via email to review the information you provided.

Thanks Again & We’ll Talk Soon!

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CaseSix Benefits Evaluation & Intake Q&A

- Step 1 of 9

Veteran's Name *

First

Middle

Last

(Middle Name or Initial)

Did You Have or Use a Different Name During Service? *

Yes
No

i.e. Legal Name Change or Marriage/Divorce

Different Name Used During Service

First

Middle

Last

(Middle Name or Initial)

Would you like to use a nick or preferred name? *

Yes
No

Nick or Preferred Name

Preferred Email *

Preferred Phone # *

Mother's Maiden Last Name

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Social Security Number Security Layer

Your Social Security Number (SS#) is important for us to review your VA information once we have completed VA Form 21-22a. To ensure the highest level of safety, we split the Social Security Number into three (3) separate fields.

For added safety, enter "XXX" in Field #1 and "XX" in Field #2. We'll contact you if and when needed. The Last Four (4) digits (Field #3) and your Last Name create your unique identifier.

First Three (3) Digits (or enter "XXX") *

Middle Two (2) Digits (or enter "XX") *

Last Four (4): *

Date of Birth *

Place of Birth *

City, State (Country if other than USA)

Birth Sex *

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Preferred contact method(s) *

Phone
Text
Email
US Mail

Check all that apply.

What is your Time Zone? (we're Eastern) *

'Other' Timezone

Please enter the Time Zone you live in. If you're not sure, this Time Zone website is helpful: https://www.timeanddate.com/worldclock/

Primary Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Housing Status *

Has accommodations
Homeless
Unspecified
Incarcerated

Employment Status *

Employed
Unemployed
Unspecified

Technology Comfort Check

This part allows us to gauge your ease with technology, ensuring we communicate and gather required files and signatures effectively. Your responses will help tailor our approach to suit your comfort level.

How comfortable are you with using QR Codes and how to use them? *

Very
Somewhat
Not at All

How comfortable are you with using Zoom or a similar video conferencing platforms to communicate? *

Very
Somewhat
Not at All

How comfortable are you with using eSignature solutions for signing documents electronically? *

Very
Somewhat
Not at All

How comfortable are you with using Dropbox for file-sharing /uploading files? *

Very
Somewhat
Not at All

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Do you have your DD214? *

Yes
No

Have you ever filed a claim with the VA? *

Yes
No

Are you currently working with another Attorney/Claim Agent (POA)? *

Yes
No

Do you currently have a claim pending with the VA? *

Yes
No

Are you receiving Disability compensation from VA? *

Yes. If so, please provide your combined percentage (next).
No

What is your Combined VA percentage (%)?

What are your Service-Connected condition(s)?

Do you have any condition(s) the VA DENIED? *

Yes. If so, please describe.
No

What are your DENIED condition(s)?

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What type of claim would you like file with the VA? *

1. Original: I have never filed.
2. New Claim: I have a new condition to claim.
3. Increased Rating: My condition has worsened
4. Reopen: VA denied my claim.
5. Higher Level Review (HLR): I disagree with the VA's decision.
6. BVA: I would like to file an appeal with BVA.

Check all that apply.

What conditions do you want to file with the VA? *

Do you have copy(ies) of VA Rating Decision letter(s)? *

Yes
No

Do you have your Military Medical Records/Service Treatment Records (STR)? *

Yes
No

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What is your current military status? *

Branch of Service. Select up to three (3) *

Army
Navy
Air Force
Marines
Coast Guard
Space Force
National Guard/Reserves
Public Health Service (PHS)
Environmental Scientific Services Administration (ESSA)
National Oceanic and Atmospheric Administration (NOAA)

What is/was your MOS (AlphaNumeric/Job Description) while in service? *

What is/was your Pay Grade? *

i.e. Enlisted, Warrant officer, Officer

What is/was your Rank? *

Military Start Date *

Military Ending Date or Projected Separation/Retirement Date *

If you are not sure of the exact date, please provide your Month and Year and use '01' as your day.

Place of Entry *

City, State, Country

Place of Separation *

City, State, Country

Military Discharge *

Honorable Discharge
General Discharge Under Honorable Conditions
Other Than Honorable (OTH) Discharge
Entry-level Separation
Medical Separation
Separation for Convenience of the Government
Bad Conduct Discharge
Dishonorable Discharge

Were you in combat? *

Yes. Where?
No

Theater(s) of Combat *

Have you ever been a Prisoner of War (POW)? *

Yes
No

If POW, START Date of Confinement

If POW, END Date of Confinement

Significant Awards: Do you have any of the following? *

None
Congressional Medal of Honor
Distinguished Service Cross
Distinguished Flying Cross
Air Force Cross
Navy Cross
Silver Star
Bronze Star
Purple Heart
Combat Action Badge
Combat Infantryman Badge
Combat Medical Badge
Armed Forces Expeditionary Medal (AFEM)

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OPTION: If you'd like to upload copies of your DD214, VA Decision Letters, STRs or the like. Please read our FILE DISCLAIMER below. Or, you can wait until after talk on the phone and we'll send you a link to your Private Dropbox.

Click or drag files to this area to upload. You can upload up to 12 files.

FILE DISCLAIMER. Every possible effort is made to ensure your files are secure and protected while in our possession. Only CaseSix authorized staff are permitted to access your files on our HIPAA compliant Google servers and are Protecting Personal Information (PPI) trained in the proper secure handling, safekeeping and destruction of your files documents. In the unlikely event your file should become lost, stolen or destroyed, CaseSix assumes no liability to you or any third parties. Furthermore, CaseSix takes no responsibility for files lost while in transit or mailed. It is your responsibility to keep copies of all information submitted to CaseSix.

Tell Us More... (if you’d like)

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Quick Survey: How did you hear about us? (Check all that apply)

Internet Search
VA Website
Vehicle Signage
YouTube Video
Facebook/Instagram
Nextdoor
LinkedIn
Twitter
Billboard
SiriusXM
Referral (If yes, please tell us who)

Personal Referral Name

First

Last

How would rate the ease of this form?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

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ALMOST DONE...

Click the hCAPTCHA to prove you are indeed a human.

Then, scroll down to the bottom of this page and click the 'Submit & Let's Go' Button. Then check your email. You'll get a complete copy right away, and CaseSix will too!

We very much appreciate you completing our Q&A. This information is beneficial in our conversation and evaluating your case.

We Will Contact You As Soon As Possible!

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Save and Resume Later

Heads up! Saving your progress now will store a copy of your entry on this server and the site owner may have access to it. For security reasons, sensitive information such as credit cards and mailing addresses, along with file uploads will have to be re-entered when you resume.

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

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Veterans! Do You Know About Your Extra VA Benefits Called "Derivatives?"

Vets who receive monthly VA compensation benefits and VA Ratings from 0% to 100% may qualify for additional benefits known as “Derivatives“?

Download Our Free Handy Disability Rating & Derivative Matrix Guide

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Veteran's Name *

First

Last

Email *

Phone (optional)

Branch of Service (select up to 3) *

Army
Navy
Air Force
Marines
Coast Guard
Nat'l Guard/Reserves
Space Force

Would you like to discuss your particular situation with CaseSix? *

1. Yes, please contact me.
2. Yes, but I will contact CaseSix.
3. No, not at this time.

Note: The information you provide is kept in strict confidence.