MVA Intake – Get Your Quotes

MVA Intake – Submit Qualified Lead

POST /receive_qualified

Lead Details

All fields marked * are required

First Name *

Last Name *

Email * Dedupe applied

Phone * Digits only. Dedupe applied.

State *

Accident State *

Injuries *

Type of Delivery *

TrustedForm URL *

Qualification Questions

What was the month and year of the accident? (Must be within the last 12 months) *

Were you at fault? * Must be NO

Were you or someone else in your car physically injured? * Must be YES

Did you or the injured person receive medical care? * Must be YES

Do you currently have an active auto insurance policy? * Must be YES

Do you currently have a lawyer representing you? * Never retained/settled (Must be NO)

Description of Accident *

Time Buckets — exactly one must be true

occurred_within_30_days occurred_31_to_60_days occurred_61_to_90_days occurred_3_to_6_months occurred_6_to_9_months occurred_9_to_12_months

Response