Law Offices of Robert B. Williams

Workers' Compensation and Social Security Disability Specialist

CONTACT INFORMATION

LAW OFFICE OF ROBERT B. WILLIAMS

33 North LaSalle Street
Suite 2119
Chicago, Illinois 60602

312.782.9400
312.444.9400 fax

Name:

Date of Birth:

Address:

City:

State:

Zip:

Area Code &
Phone Number:

- *

Area Code &
Cell Phone#:

Email Address:

Are You Currently Working?

YES

Date of latest employment:

Your job position at above date:

Date did you become disabled?

Have you already applied for
Social Security Disability?

YES

If Yes, when?

At what stage is you claim?

Are you currently under the
care of a doctor or physician?

YES

other pertinate information
regarding your disability?