Name
*
First Name
Last Name
Email
*
Date of Birth
*
MM
DD
YYYY
Branch of Service
*
Dates of Service
*
Nature of Discharge (honorable, dishonorable, etc.)
*
Rank at Time of Discharge
*
Have you filed a VA disability claim before?
*
Yes, approved
Yes, partially approved
Yes, denied
No
If denied, do you have a copy of the decision letter?
*
Yes
No
N/A
Which conditions are you claiming as service connected?
*
Are the conditions documented in your service or medical records?
*
Yes
No
Have you been diagnosed by a VA doctor or private doctor?
*
VA doctor
Private doctor
Not yet
Are you appealing a previously denied or partially approved claim?
*
Yes
No
Are you claiming conditions related to a service connected condition? (e.g. a secondary condition)
*
Yes
No
I don't know
Did you serve during any of the following periods or in the following locations?
Were you exposed to any of the following during your service?
Did you experience any of these symptoms or conditions while on active duty?
*
Yes
No
Additional Information
How would you prefer to receive communication and updates?
*
Email
Phone Call
Text Message
Phone Number
*
Country
(###)
###
####
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Certification of Truthfulness
*
I hereby certify that the information provided in this questionnaire is accurate and truthful to the best of my knowledge. I affirm that I am the individual identified in this submission and that all details about my military service history are true and verifiable. I understand that providing false or misleading information may result in delays, denial of my claim, or termination of services.
Signature
*
Today's date
*
MM
DD
YYYY
Review
*
Please review all your responses carefully before submitting this form. Ensure that your personal details (name, date of birth, and contact information) are accurate and up to date. Mistakes or incomplete information may delay the processing of your claim. if you notice any errors after submission, contact us immediately at info@victoryvca.com. By clicking "Confirm" you acknowledge that you have reviewed and verified the accuracy of your responses.
Thank you for choosing Vicorty! Your information has been successfully submitted.
Our team will review your details and contact you shortly to discuss the next steps in your claims process. if you have any additional questions in the meantime, feel free to reach out to us.
For your security, please do not send sensitive information like your Social Security number or medical records via email. Once we move forward, you’ll receive a link to upload any required documents.
We look forward to assisting you in your journey toward securing the benefits you deserve.
