americandisabilityclaims.com
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Submitted URL: https://americandisabilityclaims.com/
Effective URL: https://americandisabilityclaims.com/l1/
Submission Tags: @ecarlesi possiblethreat #phishing Search All
Submission: On October 15 via api from AU — Scanned from NL
Effective URL: https://americandisabilityclaims.com/l1/
Submission Tags: @ecarlesi possiblethreat #phishing Search All
Submission: On October 15 via api from AU — Scanned from NL
Form analysis 1 forms found in the DOM
POST /l1/submit.php
<form method="post" action="/l1/submit.php" id="application-form">
<div class="form-title">Fill out the form below to get your free claim review</div>
<div class="form-progress">
<!-- various percents defined in css -->
<div id="progress_bar" class="form-progress-percent percent-0">0%</div>
</div>
<div class="form-content">
<!-- begin step 1 -->
<div class="form-step-1">
<p class="form-text">Are you currently receiving Social Security Disability benefits?</p>
<button id="receive_benefits_no" type="button" class="form-button">NO</button>
<button id="receive_benefits_yes" type="button" class="form-button">YES</button>
<input type="hidden" id="receive_benefits" name="receive_benefits" value="">
</div>
<!-- end step 1 -->
<!-- begin step 2 -->
<div class="form-step-2">
<p class="form-text">Do you expect to be out of work for at least a year?</p>
<button id="out_of_work_no" type="button" class="form-button">NO</button>
<button id="out_of_work_yes" type="button" class="form-button">YES</button>
<input type="hidden" id="out_of_work" name="out_of_work" value="">
</div>
<!-- end step 2 -->
<!-- begin step 3 -->
<div class="form-step-3">
<p class="form-text">Have you worked for at least 5 of the last 10 years?</p>
<button id="worked_5_years_no" type="button" class="form-button">NO</button>
<button id="worked_5_years_yes" type="button" class="form-button">YES</button>
<input type="hidden" id="worked_5_years" name="worked_5_years" value="">
</div>
<!-- end step 3 -->
<!-- begin step 4 -->
<div class="form-step-4">
<p class="form-text">Are you receiving treatment from a doctor?</p>
<button id="was_treated_no" type="button" class="form-button">NO</button>
<button id="was_treated_yes" type="button" class="form-button">YES</button>
<input type="hidden" id="was_treated" name="was_treated" value="">
</div>
<!-- end step 4 -->
<!-- begin step 5 -->
<div class="form-step-5">
<p class="form-text">When did the injury occur?</p>
<span class=" col-sm-12 col-md-5">
<span class="form__radio-group d-inline">
<select name="injury_occured" id="injury_occured" class="form-control-lg" style="width:250px!important; height:32px; padding-top:8px !important; display: inline; color: #999; font-size: 11pt !important;" required="">
<option value="" selected="selected" style="font-size: 14px;">[ Select ]</option>
<option value="less_than_1_year"> Less than 1 year </option>
<option value="1_to_3_years_ago"> 1 to 3 years ago </option>
<option value="3_to_5_years_ago"> 3 to 5 years ago </option>
<option value="over_5_years_ago"> Over 5 years ago </option>
</select>
</span>
<br><br>
<p class="form-text">Do you currently have a lawyer representing your claim?</p>
<input type="hidden" id="have_attorney" name="have_attorney" value="">
<input type="radio" id="attorney_no" name="radio_attorney" value="No"> <label class="form-button" for="attorney_no"> NO </label>
<input type="radio" id="attorney_yes" name="radio_attorney" value="Yes"><label class="form-button" for="attorney_yes"> YES </label>
<p class="form-text">Any other comments about your claim?</p>
<textarea rows="5" name="case_notes" id="case_notes" placeholder="Details here" autocomplete="any-random-string"></textarea>
<div id="step_5_note_error" style="color:red; display:none;">Please enter more details</div>
<div id="step_5_error" style="color:red; display:none;">Please indicate if you are currently represented by an attorney</div>
<button class="form-button next-button" id="step5_next">NEXT</button>
</span>
</div>
<!-- end step 5 -->
<!-- begin step 6 -->
<div class="form-step-6">
<div class="form-fields">
<div class="field-group">
<label for="edit_firstname">First Name</label>
<input vtype="not_empty" type="text" id="edit_firstname" name="edit_firstname" value="" minlength="3" required="">
</div>
<div class="field-group">
<label for="edit_lastname">Last Name</label>
<input vtype="not_empty" type="text" id="edit_lastname" name="edit_lastname" value="" minlength="3" required="">
</div>
<div class="field-group">
<label for="edit_address">Address</label>
<input vtype="not_empty" type="text" id="edit_address" name="edit_address" value="" minlength="3" required="" class="pac-target-input" placeholder="Geef een locatie op" autocomplete="off">
</div>
<div class="field-group">
<label for="edit_city">City</label>
<input vtype="not_empty" type="text" id="edit_city" name="edit_city" value="" minlength="3" required="">
</div>
<div class="field-group">
<label for="edit_state">State</label>
<select vtype="not_empty" dtype="statelist" id="edit_state" name="edit_state" class="form-state-select" required="">
<option value="">State</option>
<option value="AK">Alaska</option>
<option value="AL">Alabama</option>
<option value="AR">Arkansas</option>
<option value="AZ">Arizona</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DC">District of Columbia</option>
<option value="DE">Delaware</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="IA">Iowa</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="MA">Massachusetts</option>
<option value="MD">Maryland</option>
<option value="ME">Maine</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MO">Missouri</option>
<option value="MS">Mississippi</option>
<option value="MT">Montana</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="NE">Nebraska</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NV">Nevada</option>
<option value="NY">New York</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VA">Virginia</option>
<option value="VT">Vermont</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
<div class="field-group">
<label for="edit_zip">Zip</label>
<input vtype="zip" minlength="5" maxlength="5" type="tel" id="edit_zip" name="edit_zip" value="" pattern="^\d{5}$" data-val-regex="Please enter a zip code" data-val-required="Zip is required." required="">
</div>
<div class="field-group">
<label for="edit_email">Email</label>
<input vtype="email" type="email" id="edit_email" name="edit_email" value="" pattern="^([\w\.\-]+)@([\w\-]+)((\.(\w){2,3})+)$" data-val-regex="Please enter a email address" data-val-required="Email is required." required="">
</div>
<div class="field-group">
<label for="edit_phone">Phone</label>
<input vtype="phone" type="tel" id="edit_phone" name="edit_phone" value="" pattern="^[\(]?[2-9]{1}[0-9]{2}[\)]?[.\- ]?[2-9]{1}[0-9]{2}[.\- ]?[0-9]{4}$" data-val-regex="Please enter a valid number" data-val-required="Phone is required."
required="">
</div>
<div class="field-group">
<label for="edit_phone">Date of Birth</label>
<select id="edit_dob_month" name="edit_dob_month" class="form-dob-select" vtype="not_empty" required="">
<option value="" selected="selected">MM</option>
<option value="01"> Jan</option>
<option value="02"> Feb</option>
<option value="03"> Mar</option>
<option value="04"> Apr</option>
<option value="05"> May</option>
<option value="06"> Jun</option>
<option value="07"> Jul</option>
<option value="08"> Aug</option>
<option value="09"> Sep</option>
<option value="10"> Oct</option>
<option value="11"> Nov</option>
<option value="12"> Dec</option>
</select>
<select id="edit_dob_day" name="edit_dob_day" class="form-dob-select" vtype="not_empty" required="">
<option value="" selected="selected">DD</option>
<option value="01"> 1</option>
<option value="02"> 2</option>
<option value="03"> 3</option>
<option value="04"> 4</option>
<option value="05"> 5</option>
<option value="06"> 6</option>
<option value="07"> 7</option>
<option value="08"> 8</option>
<option value="09"> 9</option>
<option value="10"> 10</option>
<option value="11"> 11</option>
<option value="12"> 12</option>
<option value="13"> 13</option>
<option value="14"> 14</option>
<option value="15"> 15</option>
<option value="16"> 16</option>
<option value="17"> 17</option>
<option value="18"> 18</option>
<option value="19"> 19</option>
<option value="20"> 20</option>
<option value="21"> 21</option>
<option value="22"> 22</option>
<option value="23"> 23</option>
<option value="24"> 24</option>
<option value="25"> 25</option>
<option value="26"> 26</option>
<option value="27"> 27</option>
<option value="28"> 28</option>
<option value="29"> 29</option>
<option value="30"> 30</option>
<option value="31"> 31</option>
</select>
<select id="edit_dob_year" name="edit_dob_year" class="form-dob-select" vtype="not_empty" required="">
<option value="">YYYY</option>
<option value="2005"> 2005</option>
<option value="2004"> 2004</option>
<option value="2003"> 2003</option>
<option value="2002"> 2002</option>
<option value="2001"> 2001</option>
<option value="2000"> 2000</option>
<option value="1999"> 1999</option>
<option value="1998"> 1998</option>
<option value="1997"> 1997</option>
<option value="1996"> 1996</option>
<option value="1995"> 1995</option>
<option value="1994"> 1994</option>
<option value="1993"> 1993</option>
<option value="1992"> 1992</option>
<option value="1991"> 1991</option>
<option value="1990"> 1990</option>
<option value="1989"> 1989</option>
<option value="1988"> 1988</option>
<option value="1987"> 1987</option>
<option value="1986"> 1986</option>
<option value="1985"> 1985</option>
<option value="1984"> 1984</option>
<option value="1983"> 1983</option>
<option value="1982"> 1982</option>
<option value="1981"> 1981</option>
<option value="1980"> 1980</option>
<option value="1979"> 1979</option>
<option value="1978"> 1978</option>
<option value="1977"> 1977</option>
<option value="1976"> 1976</option>
<option value="1975"> 1975</option>
<option value="1974"> 1974</option>
<option value="1973"> 1973</option>
<option value="1972"> 1972</option>
<option value="1971"> 1971</option>
<option value="1970"> 1970</option>
<option value="1969"> 1969</option>
<option value="1968"> 1968</option>
<option value="1967"> 1967</option>
<option value="1966"> 1966</option>
<option value="1965"> 1965</option>
<option value="1964"> 1964</option>
<option value="1963"> 1963</option>
<option value="1962"> 1962</option>
<option value="1961"> 1961</option>
<option value="1960"> 1960</option>
<option value="1959"> 1959</option>
<option value="1958"> 1958</option>
<option value="1957"> 1957</option>
<option value="1956"> 1956</option>
<option value="1955"> 1955</option>
<option value="1954"> 1954</option>
<option value="1953"> 1953</option>
<option value="1952"> 1952</option>
<option value="1951"> 1951</option>
<option value="1950"> 1950</option>
<option value="1949"> 1949</option>
<option value="1948"> 1948</option>
<option value="1947"> 1947</option>
<option value="1946"> 1946</option>
<option value="1945"> 1945</option>
<option value="1944"> 1944</option>
<option value="1943"> 1943</option>
<option value="1942"> 1942</option>
<option value="1941"> 1941</option>
<option value="1940"> 1940</option>
<option value="1939"> 1939</option>
<option value="1938"> 1938</option>
<option value="1937"> 1937</option>
<option value="1936"> 1936</option>
<option value="1935"> 1935</option>
<option value="1934"> 1934</option>
<option value="1933"> 1933</option>
<option value="1932"> 1932</option>
<option value="1931"> 1931</option>
<option value="1930"> 1930</option>
<option value="1929"> 1929</option>
<option value="1928"> 1928</option>
<option value="1927"> 1927</option>
<option value="1926"> 1926</option>
<option value="1925"> 1925</option>
<option value="1924"> 1924</option>
<option value="1923"> 1923</option>
<option value="1922"> 1922</option>
<option value="1921"> 1921</option>
<option value="1920"> 1920</option>
<option value="1919"> 1919</option>
<option value="1918"> 1918</option>
<option value="1917"> 1917</option>
<option value="1916"> 1916</option>
<option value="1915"> 1915</option>
<option value="1914"> 1914</option>
<option value="1913"> 1913</option>
<option value="1912"> 1912</option>
<option value="1911"> 1911</option>
<option value="1910"> 1910</option>
<option value="1909"> 1909</option>
<option value="1908"> 1908</option>
<option value="1907"> 1907</option>
<option value="1906"> 1906</option>
<option value="1905"> 1905</option>
<option value="1904"> 1904</option>
<option value="1903"> 1903</option>
<option value="1902"> 1902</option>
<option value="1901"> 1901</option>
</select>
</div>
</div>
<button id="submit_claim" type="button" class="form-button"> SUBMIT MY CLAIM </button>
<label>
<div class="form-terms">
<input type="hidden" id="leadid_tcpa_disclosure">
<label for="leadid_tcpa_disclosure" style="font-size:12px;"> By clicking the "Submit My Claim" button, you certify that you have provided your legal name and your own phone number, you agree to the
<a onclick="open('/terms.php','CT','resizable=no,scrollbars=yes,toolbar=no,location=no,directories=no,status=no,menubar=no,width=620,height=400'); return false;" href="/terms.php" title="Terms and Conditions">Terms and Conditions</a>
and
<a onclick="open('/privacypolicy.php','CT','resizable=no,scrollbars=yes,toolbar=no,location=no,directories=no,status=no,menubar=no,width=620,height=400'); return false;" href="/privacypolicy.php" title="Privacy Policy">Privacy Policy</a>
and authorize American Disability Claims and its
<a onclick="open('/partners','CT','resizable=no,scrollbars=yes,toolbar=no,location=no,directories=no,status=no,menubar=no,width=620,height=400'); return false;" href="/partners" title="Partners">partners</a> to contact you by email or at
the phone number you entered using automated technology including recurring auto-dialers, pre-recorded messages, and text messages, even if your phone is a mobile number or is currently listed on any state, federal, or corporate "Do Not
Call" list. You understand that your telephone company may impose charges on you for these contacts, and that you can revoke this consent at any time. For SMS campaigns Text STOP to cancel and HELP for help. Message and data rates may
apply. By clicking the "Submit My Claim" button and submitting this form, I affirm that I have read and agree to this Site’s
<a onclick="open('/terms.php','CT','resizable=no,scrollbars=yes,toolbar=no,location=no,directories=no,status=no,menubar=no,width=620,height=400'); return false;" href="/terms.php" title="Terms and Conditions">Terms and Conditions</a>
(including the arbitration provision and the E-SIGN consent) and
<a onclick="open('/privacypolicy.php','CT','resizable=no,scrollbars=yes,toolbar=no,location=no,directories=no,status=no,menubar=no,width=620,height=400'); return false;" href="/privacypolicy.php" title="Privacy Policy">Privacy Policy</a>.
</label>
</div>
</label>
</div>
<!-- end step 6 -->
</div>
<input id="edit_dob" name="edit_dob" type="hidden" value="">
<input id="edit_age" name="edit_age" type="hidden" value="">
<input id="leadid_token" name="universal_leadid" type="hidden" value="">
<input type="hidden" id="edit_lead_instance_id" name="edit_lead_instance_id" value="219838684">
<input type="hidden" id="edit_product_id" name="edit_product_id" value="61">
<input type="hidden" id="edit_crid" name="edit_crid" value="">
<input type="hidden" id="edit_afid" name="edit_afid" value="">
<input type="hidden" id="edit_cid" name="edit_cid" value="">
<input type="hidden" id="edit_sid1" name="edit_sid1" value="">
<input type="hidden" id="edit_sid2" name="edit_sid2" value="">
<input type="hidden" id="edit_sid3" name="edit_sid3" value="">
<input type="hidden" id="edit_click_instance_id" name="edit_click_instance_id" value="">
<input type="hidden" id="edit_redirect_instance_id" name="edit_redirect_instance_id" value="">
<input type="hidden" id="edit_campaign_id" name="edit_campaign_id" value="">
<input type="hidden" id="lead_is_unique" name="lead_is_unique" value="1">
<input id="edit_source_url" name="edit_source_url" type="hidden" value="https://americandisabilityclaims.com/l1/">
</form>Text Content
Accessibility ✗ - Close Add Keyboard Tabbing Turn off Animations color contrast Gray Display Increase Contrast Reverse Contrast size of text Increase Text Size Decrease Text Size Remove Font highlighting content Underline Links Underline Titles Images Titles zoom in Large Cursor Large Cursor Zoom Screen Terms Report an Issue Reset Settings Social Security Disability Benefits Evaluation You could be eligible for over $3,000 per month! Fill out the form below to get your free claim review 0% Are you currently receiving Social Security Disability benefits? NO YES Do you expect to be out of work for at least a year? NO YES Have you worked for at least 5 of the last 10 years? NO YES Are you receiving treatment from a doctor? NO YES When did the injury occur? [ Select ] Less than 1 year 1 to 3 years ago 3 to 5 years ago Over 5 years ago Do you currently have a lawyer representing your claim? NO YES Any other comments about your claim? Please enter more details Please indicate if you are currently represented by an attorney NEXT First Name Last Name Address City State State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyoming Zip Email Phone Date of Birth MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 SUBMIT MY CLAIM By clicking the "Submit My Claim" button, you certify that you have provided your legal name and your own phone number, you agree to the Terms and Conditions and Privacy Policy and authorize American Disability Claims and its partners to contact you by email or at the phone number you entered using automated technology including recurring auto-dialers, pre-recorded messages, and text messages, even if your phone is a mobile number or is currently listed on any state, federal, or corporate "Do Not Call" list. You understand that your telephone company may impose charges on you for these contacts, and that you can revoke this consent at any time. For SMS campaigns Text STOP to cancel and HELP for help. Message and data rates may apply. By clicking the "Submit My Claim" button and submitting this form, I affirm that I have read and agree to this Site’s Terms and Conditions (including the arbitration provision and the E-SIGN consent) and Privacy Policy. YOU MAY GET PAID FOR YOUR DISABILITY KEEPING YOU OUT OF WORK! FIND YOURSELF AN ADVOCATE THAT WILL FIGHT FOR YOU AND YOUR RIGHTS! If you have a medical or other serious condition that causes you to be unable to work and are before the age of retirement, you may qualify to receive monthly benefits from Social Security Disability Insurance (abbreviated to SSDI or SSD). Don’t suffer in silence, see if you qualify today. You could be eligible to receive as much as $3,000 a month! * Receive the Compensation You Deserve! * FREE No Obligation Consultation Pay Nothing! * Your Contact Information and Claim are Confidential! WHAT IT IS Social Security Disability Insurance (SSDI or SSD) is a Federal benefit program administered by the Social Security Administration (SSA), which is supported by the Social Security tax and provides aid to people who are unable to maintain gainful employment due to a permanent medical condition. SSD pays benefits to disabled individuals and certain members of their family. Anyone who has paid Social Security taxes long enough to achieve sufficient work credits and qualifies as disabled according to the definition provided by the SSA can qualify for SSD benefits. The definition of disability per the SSA is: that you are unable to perform the work you did before your disability, the SSA finds that you cannot adjust to other work due to your disability, and your disability is expected to last at least 1 year or result in death. See if you qualify to receive SSD benefits! DO I QUALIFY? •Must be 18 to 64 years of age •Not receiving benefits from Social Security •Unable to maintain gainful employment •Worked for five of the last ten years •The medical condition/disability is expected to last at least 12 months or will result in death •Able to provide medical evidence from your medical provider to support your claim •Have not been denied disability benefits in the last 60 days •Have special situations such as: blindness or low vision, are a disabled worker’s widow or widower, are a disabled Veteran, have a child disabled TAKE ACTION If you are unable to work due to a disability, don’t delay any longer! Let American Disability Claims help connect you to an SSD advocate who can determine if you qualify to receive monthly benefits from SSD. Get your FREE Disability Benefits Evaluation today – complete this easy online claim form! Copyright © 2023, AmericanDisabilityClaims Privacy Policy | Terms & Conditions | CA Residents Only - Do Not Sell My Info | California Privacy | Partners | Unsubscribe At American Disability Claims, our mission is to connect individuals seeking assistance with their Social Security Disability filing to qualified professionals who can help. THIS IS AN ADVERTISEMENT. This is not a law firm or referral service and does not provide legal advice. Our service is designed to facilitate a free connection between consumers and attorneys. Please note that while we strive to connect you with an attorney, the attorney who receives your information may not offer a free claim evaluation. This is not a substitute for medical advice from your doctor. Before making any decisions regarding your medication, always consult with a healthcare professional. We do not recommend or endorse any attorneys who pay to participate in this advertisement. The submission of our form does not establish an attorney-client relationship, and you are not obligated to retain a lawyer who contacts you through our service. Please be aware that our services may not be available in all states. American Disability Claims is not affiliated with any attorney, and we do not claim any rights to registered trademarks or brands of any company. We are here to assist you in finding the information you need to fight for your rights.