User Form – We Get Pivotal For You

Are you currently in service?

YesNo

What is you eas? This is for active duty only

While in service were you in an automobile crash?

Yes No

List your last Duty Station

0 /

Name of friend that referred you

Current Overall Disability Rating percentageIf you have never filed a claim or have no rating please put N/A here (0 is a rating only use it if your rating page says it)

Were you deployed to any combat zones in Southwest Asia and Afghanistan(Turkey, Syria, Lebanon, Cyprus, Israel, Jordan, Kuwait, Iraq, Bahrain, The United Arab Emirates, Oman, Qatar, Iran, Yemen, and Saudi Arabia The Gulf of Aden and the Gulf of Oman * The waters of the Persian Gulf, the Arabian Sea, and the Red Sea * The airspace above these locations){seeing combat only means you have been to a combat zone during operation. You do not have to be a grunt or have been on the front lines kicking indoors or being in firefights. To be considered a combat vet.}

Yes No

Were you part of an ERT (EMERGENCY RECLAMATION TEAM) that went to a crash site to help with picking up body parts or aircraft parts recovery?

Yes No

During your service, did you witness an aircraft crash or worked on an aircraft that later on crashed?

Yes No

List of medications you are currently taking for your service-connected disabilities

What was your job while you were in service

List the disabilities would you like to claim

Phone Number