GENERAL CUSTOMER QUESTIONNAIRE
Art Dannecker of the Westfield Companies developed this customer questionnaire for use by Westfield agencies:
CUSTOMER QUESTIONNAIRE
ف. From a personal viewpoint, has your interest in the purchase of insurance protection INCREASED or DECREASED within the last 3 years? ___INCREASED ___DECREASED
Why?
________________________________________________________________________
________________________________________________________________________
2. From an educational standpoint, which of the following communications media have been the most informative for you?
___ Newspaper Adv. ___ TV ___ Radio ___ Magazine
___ Agent Contact or Agency Material ___ Other
3. When was the last time your entire insurance program was evaluated and brought up to date?
Personal Protection: ___ within 1 yr. ___ 1 to 3 yrs.
___ within 5 yrs. ___ longer than 10 years ___ never
Business Protection: ___ within 1 yr. ___ 1 to 3 yrs.
___ within 5 yrs. ___ longer than 10 years ___ never
___ Minor changes made ___ Major changes made
4. How many other insurance agents/agencies do you currently do business with?
___ one ___ two ___ three ___ more than three
5. What insurance protection or other service do you purchase from them?
___ Fire/Homeowners ___ Automobile ___ Life Insurance
___ Accident & Health ___ Other (specify): ________________________________________________________________________
________________________________________________________________________
6. In your opinion, where does our agency excel in the insurance services we provide to you, your family, your profession or business?
___ Adequate Personnel ___ Claim Service
___ Telephone Courtesy ___ Office Visits with our Staff
___ Office/Accounting Procedures
___ Keeping your protection program up-to-date
___ Others: __________________________________________________________________
7. In what areas of our agency operation do you feel we can improve?
___ Claim Service
___ Office/Accounting Procedures
___ Personal Service from Staff
___ Telephone Courtesy
___ Keeping your protection up-to-date
___ Other Areas: ______________________________________________________________
8. Is our present office location convenient for you? ___ Yes ___No
Why?___________________________________________________________________
________________________________________________________________________
9. Do you feel our present office hours are adequate to serve your growing and changing insurance needs in the future?
___ Adequate ___ Should be changed
Suggested changes in present office hours:______________________
9A. Because more of our customers have indicated they would like additional time with our management people, we are considering the possibility of evening hours. Which nights would be most appealing to you?
___ Monday ___ Tuesday ___ Wednesday ___ Thursday ___ Friday
___ Would not prefer evening hours
Check hours preferred: ___ until 7 p.m. ___ until 8 p.m.
___ 6 to 9 p.m. ___ later
10. Our agency is consistently developing new ways to serve you. Please check which of the following 'Financial Services' would be of most interest to you in the future.
___ Life Insurance ___ Auto Leasing (monthly)
___ Income Tax Preparation ___ Accident and Sickness Insurance
___ Purchase of Mutual Funds ___ Real Estate/Management Service
___ Travel Service ___ Auto Financing
___ Others services which might be of interest to me: ______________________________
11. How did you originally become a customer of our agency?
___ Referral ___ Agency contacted me ___ I/We contacted Agency
___ Transfer from Another Agent or Agency
___ Other Reason (specify)___________________________________________________
12. Why will you continue to purchase your insurance protection from our agency?
___ Dependable Service ___ Up-to-Date Insurance Products
___ Capable Personnel ___ Best Agency in area
___ Other Reason: __________________________________________________________________
___ Will not continue to do business with your Agency.
Reason: _____________________________________________________________________
Special Note: Please use the following space to make any other comments or suggestions which you feel would help our agency improve our service to you in the future:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please categorize the area in which you live:
___ Within City Limits ___ Suburban ___ Rural or Farm
___ Own Home ___ Renting
Please indicate approximate age bracket for you and your wife:
___ under 25 ___ 25 -35 ___ 35-55 ___ Over 55
Please indicate your combined annual family income:
___ Under &7,500 ___ $7,500-$10,000
___ $10,000-$15,000 ___ $15,000-$25,000
___ Over $25,000
___ Husband only breadwinner ___ Wife only breadwinner
___ Both husband and wife working
Thank you very much for your thoughtful response to this important customer survey.
Your honest expression and opinions will be carefully evaluated and you can be assured we will do everything possible to deserve your continued business and confidence in the future.
--- The Entire Staff Of
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An Annual Check-Up Questionnaire
This questionnaire is sent to policyholders at least 30 days before the anniversary date. After the form comes back from the client, it is reviewed, then a personal appointment is made with those who indicated a change in their situation or who have shown an interest in some additional type of coverage.
Name ____________________________
Policy # __________________________
Date Prepared ___________________
Agent ___________________________
For me to give you the kind of professional service you deserve, I am requesting that you complete this questionnaire where applicable. Please return your review regardless of any changes in your situation, as I need to keep your file up-to-date. A postage-paid envelope is enclosed for convenience.
Thank you!
I. Since our last discussion, I have:
___ purchased a new home
___ changed my residence address
___ sold my home
___ changed my attorney to ______________________________________
___ changed my accountant to ______________________________________
___ acquired new personal assets
___ inherited securities, cash or properties
___ drawn or ___ changed my will
___ disposed of assets
___ matured or paid-up insurance policies
___ started a new savings account
___ acquired new Life insurance __________ group _________ other
___ started a new business
___ taken on or ____ dropped an associate
___ incorporated my business
___ had a gain or ___ loss in investment values
___ a member of my family or ___ firm has become disabled
___ a member of my family or ___ firm has passed away
___ my marital status has changed
___ if attending college, will graduate _________________________
___ borrowed money for business use or
___ to start a new business
II. We expect a child in _____ (month)
We had a child in _____ (month)
Name ____________________________ Birthdate _______________
Name ____________________________ Birthdate _______________
We adopted a child ____
III. My residence address is:
Street ________________________ City _____________ State____ZIP _______
Phone _________________________
Company Name ______________________
City_________________ State _____ ZIP _________
Phone ____________________________
IV. Please complete the following as to the proper names, sex, and dates of birth of yourself and immediate family.
Proper Name Sex Year and Date of Birth
____________________________ ____ ___________________
____________________________ ____ ___________________
V. Total life insurance (personal and group) on your life and your family (if married).
Year Purchased Amount Company
Yours ____________________ ______________ __________________
Spouse ____________________ ______________ __________________
Children ___________________ ______________ __________________
Name: _______________________________________________________________
This Questionnaire will become a permanent part of your file and will be used along with other information to provide you with the best personal insurance counseling. We are asking questions about Homeowners, Tenants, and Automobile insurance. If we are not writing these coverages for you, we would like the opportunity to make a cost and coverage comparison on the property we are not insuring.
HOMEOWNERS: Present amount of insurance on dwelling $___________ Expiration Date _____________
On your Homeowners you currently have $__________ coverage on your personal property. Please estimate your present-day values $_____________. (If you are interested, our office will be happy to furnish you with a household goods inventory booklet.) Homeowners also limits the amount of recovery and coverage on the following items:
- $100 on money and numismatic property.
- $1000 on manuscripts.
- $500 in the aggregate for the loss by theft of jewelry, watches, necklaces, gems, and furs.
- $500 on boats, motors, and trailers on the premises (premises coverage only).
The following are not limited in amount of recovery, but it is sometimes a good idea to list them:
1. Musical instruments 3. Cameras
2. Silverware 4. Fine arts
Do you have any of the above to specifically list or add to your policy in order to ensure their full value? Please answer even if we have them insured currently, and give their present value. Use a separate sheet if necessary and show their dollar values.
________________________________________________________________________
________________________________________________________________________
Do you use your residence for any business or office purposes?
______________________________________________________________________
Do you own a summer home or cottage?_____________________________________
Do you own any farm property? ____________________________________________
Do you own any dwellings rented to others? __________________________________
Do you own any recreational vehicle such as a golf cart, snowmobile, or go-cart?______
Do you own a boat? _________ If so, please give length _________,
motor horsepower_____________, inboard or outboard __________,
value of boat $________________, motor $__________________, and
boat trailer $__________________________.
There are a great many optional coverages available. Please indicate if you are interested:
1. Credit Card and Forgery Interested? ____ Not Interested? ____
2. Earthquake: Interested? ____ Not Interested? ____
3. Umbrella Liability Interested? ____ Not Interested? ____
[includes excess major medical]
4. Mortgage Protection Life Insurance: Interested? ____ Not Interested? ____
5. Other Life Insurance or Financial Planning Service: Interested? ____ Not Interested? ____
Replacement costs have increased 25% in the last 3 years. Do you carry enough insurance? ______ If you can, please give us the year your house was built and the cost of construction, excluding land ________________________________________________
Construction of home: Masonry ______ Brick Veneer _________
Frame _______ Mixed ______ % _________
Typee of roof __________
Is basement finished? ________________
If your house is not insured to 80% of replacement value, you can be penalized at time of loss.
AUTOMOBILE Expiration Date______
Types of Cars Use (pleasure, business)
1.____________________ ___________________________
2 ____________________ ___________________________
3.____________________ ___________________________
Drivers Age Occupation
1. __________________________________________________________________
2. __________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
List who has had accident(s) or violation(s) in the last three years and what the violations were for.
________________________________________________________________________
Does your Auto policy contain 'Accidental Death and Disability' coverage?
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If you own a pickup do you have a camper which could be attached?
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