Claims Satisfaction Survey

First Name

Last Name

Email

Claim Number

Date Claim Occurred

Claim Representative

Please select a representative.

	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	Not Applicable
I was satisfied with how quickly the adjuster contacted me after I reported my claim.	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	Not Applicable
The reporting of my claim was easy and convenient	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	Not Applicable
I was satisfied with how quickly my automobile or home was inspected.	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	Not Applicable
I was satisfied with how quickly my claim was paid.	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	Not Applicable
Overall, my expectations were met.	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	Not Applicable

Additional Comments

Would you like to be contacted?

Yes

No

Name of Contact

Contact name is required.

Phone Number

Enter a valid phone number.

Best Time to Call

Contact time is required.

Reason for Contact