Alert Form
Time of Call
*
Your Answer
Full Name
*
Cell Number
*
Email
Source Alert
Call Source:
Reason for Call:
Your Answer
Lead Intake Questions
When did the accident or injury occur?
Your Answer
Call Center Survey - How were you injured?
How were you injured?
What injuries did you suffer?
Have you received medical treatment ?
Your Answer
Do you currently have a lawyer ?
Your Answer
Additional Comments :
Let the caller know you will deliver their message promptly.
To
To
Name of person you are leaving a message for
Detailed Message :
Were you able to successfully transfer the call?
Your Answer
Please let the caller know that you would like to have an investigator give him/her a call shortly.
Reason For Call:
Your Answer
As an intake specialist, I’d like to gather some initial information about your injury.
When did the accident/injury occur ?
Your Answer
Alert Survey - After Hours - How were you injured?
Alert Survey - After Hours - How were you injured?
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?
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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