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Street Address
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Date of Birth
Date of Last Denial Notice MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDate12345678910111213141516171819202122232425262728293031Year197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011
Date You Last Worked
At What Stage is Your Claim
Why do you believe you are disabled and not able to work at any type of job?
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PHONE: 425-641-6000
FAX: 425-641-1745
1800 112th Avenue NE, Suite 300E
Bellevue, Washington 98004
