ReferraLink Disposition Form 2024
Use this form to disposition your Referral Partner Enrollments. This will trigger payments to you Referral Partners. Note: You must register your Referral Partner at least 7 days prior to receiving a Referral in order for them to be eligible to receive a referral payment.
Agent Name
*
First Name
Last Name
Email
*
example@example.com
Referral Partner Name
*
Referral Partner Number (if known)
Customer Name
*
What type of enrollment was this?
*
New To Medicare
Plan to Plan Change
What product?
*
MAPD
MA
Long Term Care
Life Insurance
Which Carrier?
Date of Enrollment
-
Month
-
Day
Year
Date
Date Fee Paid (Leave Blank)
-
Month
-
Day
Year
Date
Notes:
Submit
Should be Empty: