SSDC Referral Form

SSDC Referral Form
Please contact SSDC with eligibility questions:

800-374-9950 x222

www.ssdcservices.com

Referral Fee:

$100 if SSDC takes on the case and $100 if they win the case. Referral fees will be paid by Agent Equity Group.

Referring Agency Information:

Agent Equity Group

2025 E. Beltline Ave. SE, Suite 402

Grand Rapids, MI 49546

Referring Agent Information:

Provide the information below for the agent to whom the referral fee will be paid if an SSDI case is opened:
Agent Name*

First NameLast Name
Agent Email*
example@example.com
Agent Cell Phone*
Please enter a valid phone number.
Agent Office Phone
Please enter a valid phone number.
Disabled Individual Information:

Provide information for the disabled individual that means the following criteria:
Referral Criteria:

• Ages 18 – 64 1⁄2
• Currently not enrolled in Medicare

If the individual meets the above criteria and the answer is “Yes” to all 3 questions listed below, the individual can be referred to SSDC for additional screening.

1. Has a medical condition that would prevent full time work?
2. The medical condition is expected to last at least 1 year?
3. Sees a doctor for disabling condition?
Referral Name*

First NameLast Name
Referral Address*

Street Address

Street Address Line 2

CityState

Zip Code
Referral Email*
example@example.com
Referral Phone*
Please enter a valid phone number.
Comments
Please verify that you are human*
Should be Empty: