Disability Information Current Rate: Potential Rate: Difference Rate: Disability Income Over Time # Current Potential Difference 1 Mon 6 Mon 1 year 5 years 10 years Back Pay Details Rating Information: Current Rating Select 10 20 30 40 50 60 70 80 90 100 Potential Rating Select 10 20 30 40 50 60 70 80 90 100 Marital Information: Marital Status Select Single Married Does Your Spouse Need Aid & Assistance? Yes No Dependant Information: Number of Dependent Children Under the Age of 18 Select 1 2 3 4 5 6 7 8 9 None Number of Dependent Children Between the Ages of 18 to 24 1 2 3 4 5 6 7 8 9 None Number of Dependent Parents Select 1 2 None Back Pay Information: Months: Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
