Home Services Survey Form

Home Services Survey

This survey will help us explore your best options to reduce your bills and/or capture a better value.
Who referred you? Name of the Independent Business Owner*

First NameLast Name
IBO Number - if applicable
Customer's Name*

First NameLast Name
Address (No P.O. Box):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*

Area CodePhone Number
E-mail*
example@example.com
HEALTH CARE
YesNo
How many members are in your plan?
How much is your monthly payment?
YesNo
YesNo
If yes, please provide the birthday of the oldest member in the household.
Date of Birth:

MonthDayYear
Birthday of the oldest member
Number of members:
MOBILE CELL PHONE SERVICE
Who is your Cell Phone Company?*
e.g., Verizon, T-Mobile, AT&T etc.
How many lines do you have in your plan?*
How much is your monthly plan?*
YesNoI'm not sure
YesNo
IDENTITY THEFT PROTECTION
YesNo
If yes, who is your current provider?
If yes, how much is your monthly protection?
YesNo
If yes, who is your current provider?
If yes, how much is your monthly protection?
YesNo
SECURITY & AUTOMATION
YesNo
YesNoI do not have a Security System
If yes, who is your current provider?
YesNo
If yes, what is the best day and time to get a free quote from Vivint?
Date*

MonthDayYear
HourMinutesAM/PM Option
Central TimeEastern TimeMountainTimePacific Time
GAS & ELECTRICITY

(available only in deregulated states)
What state do you live in?
Fixed RateVariable RateI'm not sure
YesNo
NOTE: Please have your most recent utility bill ready.
INTERNET
YesNo
Internet Speed?
ex: 300 Mbps, 500 Mbps, 1000 Mbps, etc.
Current provider?
NonePhoneTelevisionMobile
How much is your monthly bill?*
YesNo
TELEVISION
YesNo
Current provider?
How much is your monthly bill?
When does your contract(s) expire?
YesNo
YesNo
Thank you for taking the time to fill out this survey. Your support in my business means the WORLD to me. I'd appreciate any referrals you can think of. Thank you!
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