Initial Ticket Intake Form

Customer Service Intake & Information
Initial Call Date*
MM slash DD slash YYYY
Initial Call Time*

: Hours

Minutes

AM/PM
Ticket Number

Please note that the field is optional. (Most people calling don't have a ticket number.)
Caller Name*
First Last
Caller Phone No*
Caller Email*
Best Contact Method*
- Phone
- Email
OK to Leave Message?*
- Yes
- No
Is foreign language assistance required?*
- Yes
- No
Language Needed*
Client/Group Name & Toll-Free Number*
Please refer to Client Line Name/Number.
Subscriber Name
(if different from caller name)
Reason for Call (Open Ticket)
Reason for Call*
Description of Request*
Please enter a brief description of the issue as presented by the caller.
Other Notes (from the Tier 1 Advocate)
Provide available demographic and policy data. (Please refer to script.)
Note to CSP: Before you submit the ticket, please return to the script to patch the call. Once the patch attempt is completed, please return and submit the web form.
Name
This field is for validation purposes and should be left unchanged.

Customer Service Intake & Information