Date* MM slash DD slash YYYY Reference ID:HiddenSurvey Type1=Consumer Research 2=For a Job InterviewHiddenApplicant InformationHiddenApplicants Name (or referred by):* First Last Your InformationYour Name* First Last Email* Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you use an agent or do you purchase insurance direct?*Direct - GEICO, USAA, eSurance Agent Direct Both SURVEY: Purchased Through an AgentFrom the choices below, which types of insurance do you purchase through an insurance agent?* Auto Home Second Home Renters or Condo Health Life Motorcycle Umbrella Business Auto Business Property Annuities or Investments Recreational SURVEY: Purchased DirectFrom the choices below, which types of insurance did you purchase direct from a company like GEICO?* Auto Home Second Home Renters or Condo Health Life Motorcycle Umbrella Business Auto Business Property Annuities or Investments Recreational Satisfaction with Insurance AgencyHow long have you had insurance through this agency?*Over 10 yearsOver 5 years3-5 years1-3 yearsLess than 1 yearLess than 1 Year | 1-3 Years | 3-5 Years | 5-10 Years | Over 10 YearsReason why you chose to purchase through your agent:*Of the reasons identified below, what was the primary reason you choose to do business with that agency. Referral Agent is Family or Long Time Friend Price Great Service Trust How often do you communicate with your current insurance agent?*Once per Month | Once per Year | Less Than Once Per Year | Seldom if EverSeldom if EverLess than once a yearOnce a yearOnce a monthDid your agent provide a professional sales presentation with coverage options when you purchased your insurance policy?* Yes No Not Certain Does your agent offer to review your insurance policies to make certain you have every discount you are entitled to receive?* Yes No Not Certain What do you love about your insurance agent, or why do you choose to stay with your current agent?* What do you wish your agent would improve or do better to service your insurance and financial services needs?*If you provide a detailed answer that we have not heard and will implement into our agency, you will receive a custom YETI Coffee mug!Overall satisfaction with current insurance agent.*1-Very Unhappy | 2-Unhappy | 3-No Opinion | 4-Happy | 5-Very Happy5 - Very Happy4 - Happy3 - No Opinion2 - Unhappy1 - Very UnhappySatisfaction with Direct Insurance CarrierReason why you chose to purchase direct:*Of the reasons identified below, what was the primary reason why you choose to do business with that agency. Technology Convenience Price Great Service Agent's Don't Add Value How long have you had insurance through this company?UncertainOver 5 years3-5 years1-3 yearsLess than 1 yearLess than 1 Year 1-3 Years 3-5 Years 5-10 Years Over 10 YearsApplicant RecommendationThe person that referred you to this site may be interviewing for a position in our agency. Based on your relationship with this person, please answer the questions below. Your answers will be confidential.This person has exceptional customer service skills.*Strongly disagreeDisagreeNeutralAgreeStrongly agreeThis person loves to help others.*Strongly disagreeDisagreeNeutralAgreeStrongly agreeIf hired, I would allow this person to quote one or more of my insurance policies.*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI would recommend this person for a job in the insurance field.*Strongly disagreeDisagreeNeutralAgreeStrongly agreeYour personal recommendation:If you would like to provide more details about why you would personally recommend this candidate for hire, please do so below.Submit SurveyAre you ready to submit? Yes No Would you like a comparison quote from our agency?* Yes No thank you. No, but maybe in the future. What type of quote would you like us to prepare?Select all that apply. Auto Home Life Business Flood Motorcycle or Recreational Vehicle Retirement Planning College Savings Plan Other AddressIf you win our drawing, where would you like your gift to be mailed? Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code When should we check back with you? MM slash DD slash YYYY Cell Phone*HiddenYesTotal: Yes I would Like a QuoteHiddenLead Source Applicant Survey
