Kurt R. Ward - Attorney at Law, LLC

NFL Disability Questionnaire

Full Name: First Middle Last
Commonly Known As: First Last
Email: Email
Home Phone: - (###) - ### ####
Cell Phone: - (###) - ### ####
Address:

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code
What seasons did you play in the NFL?

Are you disabled? Yes No
Did your disability arise out of NFL related injuries? Yes No
Have you ever applied for NFL Disability Plan benefits? Yes No
Are you receiving Social Security Disability (SSDI or SSI)? Yes No
Are you currently working? Yes No
If yes, do you have a physical or mental condition that affects your ability to work? Yes No
If no, when did you stop working?
Do you have copies of your medical records? Yes No