Alert Form
Time of Call
*
Your Answer
During Regular Office Hours (M-Th 8:30 - 4:30, F 8:30 - 4:00)
After Hours (Weekends, Holidays, 4:30 pm - 8:30 am)
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Full Name
*
Cell Number
*
Email
Source Alert
Call Source:
None
SEO
PPC
LSA
Existing Client
Google
GMB
LPN
Website
Lawyer.com
Convert IT
You Tube
CLC
Accident.com - Maryland
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Reason for Call:
Your Answer
Lead
Existing Client
Other
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Lead Intake Questions
When did the accident or injury occur?
Your Answer
Within the last 30 days
1 - 3 months
More than 3 months ago
Unsure
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Call Center Survey - How were you injured?
How were you injured?
Car Accident
Truck Accident
Motorcycle Accident
Dog Bite
Slip & Fall
Other SERIOUS injury
Other injury
Unsure
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What injuries did you suffer?
Have you received medical treatment ?
Your Answer
Yes
No
Unsure
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Do you currently have a lawyer ?
Your Answer
YES
NO
Unsure
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Additional Comments :
Let the caller know you will deliver their message promptly.
To
To
Attorney
Staff
Other
Unknown
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Name of person you are leaving a message for
Detailed Message :
Were you able to successfully transfer the call?
Your Answer
YES
NO
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Please let the caller know that you would like to have an investigator give him/her a call shortly.
Reason For Call:
Your Answer
Lead
Existing Client
Other
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As an intake specialist, I’d like to gather some initial information about your injury.
When did the accident/injury occur ?
Your Answer
Within the last 30 days
1 - 3 months
More than 3 months ago
Unsure
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Alert Survey - After Hours - How were you injured?
Alert Survey - After Hours - How were you injured?
Car Accident
Truck Accident
Motorcycle Accident
Dog Bite
Slip & Fall
Other SERIOUS injury
Other injury
Unsure
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List is empty.
What injuries did you suffer ?
Have you received medical treatment?
Yes
No
Unsure
Do you currently have a lawyer?
Yes
No
Unsure
Additional Comments
AGENTS: If the caller was involved in a motor vehicle accident, suffered a dog bite, or other is currently dealing with serious injuries, attempt a transfer to the on call number.
Was the transfer successful?
Was the transfer successful?
Yes
No
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Let the caller know you would like to have an investigator give him/her a call shortly.
Let caller know you'd like the team to review and an investigator will follow up.
Please click below to complete the submission.
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