* 1. On a scale of 1 to 5 how would you rate your service from Premier?

* 2. In a few sentences, please tell us about your experience with Premier Disability. Box will extend if you need more space to type.

* 3. Please enter your full name. First name followed by your last name. (i.e. Joe Smith)

* 4. What is your email address?

* 5. I understand and consent to the use and release of this testimonial. I understand that the testimonial is for marketing purposes. I relinquish any rights to compensation for my testimonial and understand the testimonial may be used by Premier Disability, LLC without further permission.

* 6. Is there a specific person at Premier Disability Services that you would like to recognize for the great customer service they provided? 

* 7. Do you have any friends or family that may need our help in filing for Social Security disability?

* 8. If you answered yes to question 7, do we have permission to mention your name when we call?