SSDI Intake Form
Personal Information
Full Name
*
Email
*
Phone
*
Social Security Number
*
Date Of Birth
Gender
*
Male
Female
Address
*
Street Address
City
State
Country
Enter your country
Postal Code
Is the above also your mailing address?
Yes
No
If no, mailing address
Place of Birth (City and State/Country)
Mother’s maiden name
Preferred Language
Weight without shoes
Height without shoes
Medical Information
Disabilities
Date you became severely disabled
*
Are you a U.S. Citizen
*
Yes
No
If not, are you a Lawful Permanent Resident (Green Card holder)
Yes
No
Date Green Card was first issued
Green Card expiration date
If no, please explain your current alien status
Family and Dependent Information
Current Marital Status
Spouse Name
Spouse SSN (If known)
Date and place of marriage
Prior Marriage (if applicable)
Ex-Spouse’s Name
Date of Marriage
Date Marriage Ended
Did the marriage end due to
Divorce
Death
Other Dependent Children
List names and ages
Work History and Other Benefit Claims Information
Current Employment Status
Not working
Working Part-time
Working Full-time
If not working, date stopped and reason
If working, are you earning more than $1,690/month?
Yes
No
Workers’ compensation
Unemployment benefits
Long-term disability
Short-term disability
Other
Job Title #1
Company Name #1
Company Address #1
Dates From #1
Rate of Pay #1
Hours per Week #1
Days per Week #1
Job Title #2
Company Name #2
Company Address #2
Dates From #2
Rate of Pay #2
Hours per Week #2
Days per Week #2
Job Title #3
Company Name #3
Company Address #3
Dates From #3
Rate of Pay #3
Hours per Week #3
Days per Week #3
Medical Records & Treatment History
Facility/Doctor Name #1
Specialty #1
Phone #1
Full Address #1
First Visit Date #1
Last Visit Date #1
Upcoming Appointments #1
Yes
No
Medical Date #1
Reason for Treatment #1
Facility/Doctor Name #2
Specialty #2
Phone #2
Full Address #2
First Visit Date #2
Last Visit Date #2
Upcoming Appointments #2
Yes
No
Medical Date #2
Reason for Treatment #2
Medications Details
Submit