Bett On Benefits LLC (Veteran Intake Questionnaire)
Full Name
*
Date of Birth
*
Email Address
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Phone Number
*
Preferred Method of Contact
*
Call
Text
Email
Branch of Service
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Army
Navy
Air Force
Marine Corps
Coast Guard
Space Force
Date of Service From
*
Dates of Service To
*
Primary MOS / Job Title
*
Duty Location
*
Are you currently serving (Active, Guard, or Reserve)?
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Yes
No
Current VA Disability Rating (if known)
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0%
10–40%
50–90%
100%
Not yet rated
Are you currently receiving?
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VA Disability Compensation
SSDI (Social Security Disability)
Military Retirement
None of the above
Have you previously filed for any of the following?
*
VA Supplemental Claim (20-0995)
Higher-Level Review (20-0996)
Board Appeal (10182)
TDIU (Individual Unemployability)
Combat-Related Special Compensation (CRSC)
Which conditions are you seeking help with?
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Physical
Mental
Secondary
Have you had a Compensation & Pension (C&P) Exam?
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Yes
No
Not Sure
Were you referred by someone?
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Yes
No
How did you hear about BETT_ON Benefits?
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Social Media (Facebook / Instagram / TikTok)
YouTube or Podcast
Word of Mouth
Veteran Event or Flyer
Other (please specify):
Would you like to earn a referral incentive for helping other veterans get the benefits they deserve?
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Yes, Send me more info
Maybe Later
Have you worked with another consultant or representative before?
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Yes
No
What are your main goals for working with BETT_ON Benefits?
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Please share anything else you think we should know?
Verification and Submission
*
By submitting this form, you agree to be contacted by BETT_ON Benefits at the phone number or email provided for assistance with your VA benefits review.
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