Home
Working with CaseSix
Insiders Claims Guide

Menu

Home
Working with CaseSix
Insiders Claims Guide

Search

Search

Close this search box.

Intake & Eligibility Review Q&A

CaseSix 3D BUG & 2D TEXT Rev 5a Blue & Red

READ ME

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!

Please enable JavaScript in your browser to complete this form.

CaseSix Benefits Evaluation & Intake Q&A

- Step 1 of 9

Veteran's Name *

First

Middle

Last

(Middle Name or Initial)

Nick or Preferred Name

Vet's Maiden Name (if applicable)

Mobile Phone # *

Preferred Email *

Primary Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Mother's Maiden Last Name *

(We use your Mother's Maiden Last Name to create your Unique Password.)

Marital Status *

Married
Single
Divorced
Widowed

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, simply enter "XXX" in Field #1 and "XX" in Field #2. You can tell us the rest of your SS# when we talk. At the minimum, we need the Last Four (4) digits (Field #3) to 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 *

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/

Employment Status *

Employed
Self Employed (LLC, Inc. or Org.)
Unemployed
Unspecified

Housing Status *

Has accommodations
Homeless
Incarcerated
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? *

Very
Somewhat
Not at All

How comfortable are you with using Video Conferencing platforms to communicate? *

Very
Somewhat
Not at All

Like Zoom, Google Meet, WebEx and the like.

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

Very
Somewhat
Not at All

Like DocuSign, Dropbox Sign, VineSign, etc.

How comfortable are you with using File Sharing for Uploading/Downloading files? *

Very
Somewhat
Not at All

File Sharing platforms include Dropbox, Filevine, iCloud, Google Drive, OneDrive, and the like.

Do you have your DD214? *

Yes
No

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

Yes
No

Do you have Private Treatment (TX) or Diagnosis (DX) Records? *

Yes
No

Private Treatment (TX) or Diagnosis (DX) Records are from your Family Doctor, Specialist or VA Medical Center.

Have you ever filed a claim with the VA? *

Yes
No

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

Yes
No

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

Yes
No

Date Your VA Form 21-0966 (Intent to File) Was Filed with VA?

VA Form 21-0966 begins your filing process and allows up to 1 Year to gathering information and evidence in support of your claim. Submitting the Intent To File (ITF) secures the earliest possible effective date for any retroactive payments you may be eligible for.

Are you receiving Disability compensation from VA? *

Yes
No

If Yes, please provide your combined percentage (next).

What is your Combined VA Rating Percentage (%)? *

Vets with a Rating of 30% or Higher are Entitled to Increased Benefits. *

This refers to VA Form 21-686c (Add/Remove Dependents). Vets with a Rating of 30% or higher are entitled to increased benefits if they have • a Spouse • Child(ren) under age 18 • Between the ages of 18 & 23 who are attending school • Over 18 who are permanently incapable of self-support &/Or • Dependent parent(s).

Subsequent VA Forms are 21-674: Request for School Attendance &/Or 21-509: Statement of Dependent Parent(s)

Check All That Apply. (Refers to VA Form 686c)

Spouse
Previous Marriage
Dependent Child(ren)
Dependent Parent(s)

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)?

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

Yes
No

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? *

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

Army
Navy
Air Force
Marines
Coast Guard
Space Force
Army National Guard/Reserve
Air National Guard/Reserve
Coast Guard Reserve
Marine Corps Reserve
Navy Reserve

What is your current military status? *

Military Discharge/Character of Service *

Honorable
General
Under Hororable Conditions
Other Than Honorable (OTH)
Entry-Level Separation
Medical Separation
Separation for Convenience
Bad Conduct
Dishonorable

What is/was your Rank? *

i.e. PFC, PO3, SSgt, CPO, SgtMajMC

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

i.e. 13F - Joint Fire Support Specialist

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

Were you in combat? *

Yes. Where?
No

Theater(s) of Combat *

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/Ribbon
Combat Infantryman Badge/Ribbon
Combat Medical Badge/Ribbon
Armed Forces Expeditionary Medal (AFEM)

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)

Let's Wrap It Up.

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

What Size T-Shirt Do You Wear?

Think standard men's size.

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!

CaseSix Main Transparnt Background Rev 2 WHITE & Red

Your Case. Your Six.

© 2024 CaseSix, LLC. All Rights Reserved

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

Please enable JavaScript in your browser to complete this form.

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.