CLAIM INFORMATION FORM
Please fill in as much information as possible. If you have your DD214 please upload. IF A FIELD IS NOT APPLICABLE PUT N/A. Fill in the required field
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Full Name:
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Email:
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Tel. Number:
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Is This Your Mobile Number?:
Yes
No
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Date of Birth:
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Branch of Service:
ARMY
NAVY
AIR FORCE
MARINES
COAST GUARD
SPACE FORCE
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Home Address:
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Military Rank/Pay Grade?:
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When Join Military?:
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When Leave Military ETS?:
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Ever Applied For Benefits?:
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Ever Served in War? In or near or as a support unit?:
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If Ever Served in War list what War and year:
List Duty Locations?:
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Where were you born?:
List Type of Illness and Injuries:
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When Illness or Injury Occured? (Dates & Locations):
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Who have knowledge of illness? (Family-Friend?) Give Names:
List Treatment Locations (NAME and ADDRESS):
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Where You Joined Military (CITY, STATE):
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Are You Being Treated (Currently)?:
List Where you were stationed? (HOW LONG):
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Claim Type:
-Choose Type-
Disability
Pension
Survivor
Education
Healthcare
Dependents
Funeral Honors
DD214 Update
How To Add Dependents
How To Request Funeral Honors
How To Complete DD214 Update
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Subject:
-Choose Subject-
Ready To Apply
General Questions
Nearest VA Facility
How To Apply
How To Order DD214
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How has your illness/injuries effect overall life?:
Upload File:
Accepted Extension: png, pdf, jpg, jpeg, gif and up to 4mb
Upload File:
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Location:
Columbus, US
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