"Thank you for calling The Disability Guys, this is {name}, how can I help you?"

Any details included in the response to this question should be added to the 'Additional Details' field at the end

"I'm sorry this happened. I need to gather some information for the attorneys to see how they can better assist you. May I have your first and last name please?"

Primary Contact Information

Caller First Name *

Caller Last Name *

Primary Contact Phone Number *

Dialpad Caller ID Phone Number *

Primary Contact Email

Address *

Street Address *

State *

City *

Zip Code *

Is the caller also the potential client? *

Alternate Contact Information

Potential Client First Name

Potential Client Last Name

Potential Client Phone Number

Best time to reach the contact person? *

Primary language of the Caller: *

English

Spanish

Other

Incident Information

Markhoff & Mittman - Case Type *

Date of Incident *

Name of Employer *

Where did the Incident Happen? *

Summary of Incident *

Injuries Sustained *

Nature of disability or medical condition? *

When Were They Diagnosed? *

Have they filed for Social Security Disability or any other benefits? *

Yes

Which benefits have they filed for?

Has a decision been received?

Yes

What was the decision?

When did they last work?

Have You Worked And Paid Taxes For 5 Of The Last 10 Years

Select one

What physical/mental challenges prevent them from working?

Are they seeing a physician for these conditions?

Yes

Does their physician say they are unable to work?

Yes

How long have they been out of work due to their disability?

What type of work were they doing when they became disabled?

Do they have any household income?

How Can the Firm Help? *

Hospitalization or Medical Attention? *

Hospitalization

Medical Attention

None

Did they report the incident to the police? *

Yes

Did they report the incident to their employer? *

Yes

Did they report the incident to anyone else? *

Yes

Who did they report the incident to?

Talked To Other Attorneys *

Yes

select one

What did the attorney tell them?

Additional Details

How did you hear about Markhoff & Mittman? *

Standard Call Ending:

"Thank you (Caller's Name) for contacting Sullivan Brill. I’m going to send all this information over to the attorneys now for their review and they will call you back within 24 hours."

"Is there anything else I can do for you?"

"Thank you again for calling, have a great day/night."