MVA CPQ Lead Qualification
Important Instructions for Agents
ACCEPTED States
Only these states are accepted:
AL
AZ
CO
CT
GA
IL
KY
MA
NC
NE
NH
NM
NV
OH
OK
OR
TN
TX
UT
DISQUALIFICATION Criteria
Accident >12 months ago (11 for TN/KY)
First treatment >14 days after accident
Gap in treatment >60 days
Claimant was at fault
Received moving citation
Prior injury settlement
Has attorney (in TX) or won't switch
Special Rules
TN & KY:
11 months accident window
All States:
14-day initial treatment window
TX:
Auto-DQ if has attorney
All States:
60-day max treatment gap
Prequalification Questions
In which state did the accident occur?
*
(Select from accepted states only)
-- Select State --
Alabama (AL)
Arizona (AZ)
Colorado (CO)
Connecticut (CT)
Georgia (GA)
Illinois (IL)
Kentucky (KY)
Massachusetts (MA)
North Carolina (NC)
Nebraska (NE)
New Hampshire (NH)
New Mexico (NM)
Nevada (NV)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Tennessee (TN)
Texas (TX)
Utah (UT)
What date did the motor vehicle accident occur?
*
(Format: MM/DD/YYYY - Must be within last 12 months, 11 for TN/KY)
Were you injured as a result of this accident?
*
Yes
No
Did you receive medical attention/treatment for your injuries?
*
Yes
No
Are you willing to undergo treatment?
*
(Only asked if no treatment AND accident within 30 days)
Yes
No
When was your first treatment for these injuries?
*
(Must be within 14 days of accident)
Have you had any gap in treatment longer than 60 days?
*
No (Gap ≤ 60 days)
Yes (Gap > 60 days)
Were you found to be at fault for the accident?
*
(Answer must be NO to qualify)
No (Correct Answer)
Yes (Disqualifies)
Did you receive a moving citation for the accident?
*
(Answer must be NO to qualify)
No (Correct Answer)
Yes (Disqualifies)
Was a police report filed?
*
Yes
No
Are you currently represented by an attorney?
*
(Auto-DQ in TX if Yes)
No (Preferred)
Yes
Are you looking to switch attorney representation?
*
(Only asked if has attorney and not in TX)
Yes
No (Disqualifies)
Have you ever had legal representation for this incident?
*
No
Yes
Did your previous attorney decide not to proceed?
*
No
Yes (Disqualifies)
Have you received a settlement for this or prior injury?
*
(Answer must be NO to qualify)
No (Correct Answer)
Yes (Disqualifies)
Check Prequalification
Intake Information
Collect claimant details for API submission
First Name
*
Last Name
*
Email Address
*
Phone Number
*
(For callerid in API)
Zip Code
*
SMS Consent
*
OptIn (Yes)
None (No)
Data to be sent to Ringba API:
Submit to Ringba API
Back to Prequal