Connect2Attorney – SSDI for Advocate Rights Center SSDI EDL Lead Submission

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Required Information *
First Name is required.
Last Name is required.
Please enter a valid email address.
10-digit phone number required.
10 digits, no country code needed
Street address is required.
City is required.
State is required.
5-digit zip code required.
SSDI Eligibility Questions (optional but recommended)
Do you have any disabilities or conditions that have caused you to be out of work for the last 12 months?
Are you between 50–63 years old?
Are you currently working with a Disability Attorney?
Are you currently employed?
Do you expect to be out of work for the next 12 months?
Are you currently receiving Social Security, Social Security Disability or Supplemental Security Income?
Are you currently receiving medical treatment or seeing a doctor for your disability/condition?
Do you take prescribed medications for your disability?
Compliance & Tracking *
At least one of the following is required
Either TrustedForm URL or Jornaya Lead ID is required.
Either TrustedForm URL or Jornaya Lead ID is required.
Test lead warning: Please use Test as First Name and Lead as Last Name for test submissions. Standard names will be treated as real leads and may be contacted (TCPA compliance).