Welcome  Denotes Required Fields Your Name : Your Email Address: Company (if applicable): Phone:
	Are you a current customer?		Yes No
	What recent transaction have we handled for you?		Recent Transaction A - New Policy B - Quote C - Renewal D - Claim E - Billing Issue F - Policy Change G - Registration Issue H - General Info Request I - Other
Grade Us	Overall customer service		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
	Binder, certificate, policy issuance		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
	Claims Handling		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
	Return call promptness		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
	Courtesy of customer service rep		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
	Customer service rep's product knowledge/service		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
	Responsiveness to special needs		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
	Billing accuracy		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
	Resolves mistakes quickly		Grade Us A - The Best B - Above Average C - Average D - Needs Improvement F - Terrible
Referral	Would you refer a prospective customer to us?		Would you refer us? Yes No
	If yes, please share your referral's name and address so we can send information about our company.
Suggestions	If we didn't meet your needs, how can we improve our services or products?
	Please press just once. Allow a minute or so for form to process, be patient...

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Georgetown Insurance
10 West Main Street • Georgetown, MA 01833
978-352-8000 • FAX 978-352-7719

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