Clone of Clone of Home Services Survey

Who referred you. If it is yourself then add your own name):

First NameLast Name

REP Number

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

Do you have health insurance?

If yes, how many members are in your plan?

If yes, how much is your monthly payment?

Are you interested in a free quote?

If yes, please provide the birthday of the oldest member in the household and the number of members.

Date of Birth:

Birthday of the oldest member

Number of members:

IDENTITY THEFT PROTECTION

Do you currently have Identity Theft Protection?

If yes, who is your current provider?

If yes, how much is your monthly protection?

Do you currently have Device Protection?

If yes, who is your current provider?

If yes, how much is your monthly protection?

Are you open to explore our options?

If yes, how many adults?

If yes, how many kids?

SECURITY & AUTOMATION

Do you have a doorbell camera or smart home equipment?

If yes, is it integrated with your Security system?

If yes, who is your current provider?

If yes, when does your contract(s) expire?

If yes, how much is your monthly bill?

Are you open to explore our options?

If yes, what is the best day and time to get a free quote from Vivint?

Date

Time:

:HourMinutesAM/PM Option

Time Zone:

GAS & ELECTRICITY

Do you pay for ELECTRICITY in any the following states?

Current Electric State

Do you pay for GAS in any the following states?

Current Gas State

Are you open to explore our options?

NOTE: Please have your most recent utility bill ready.

MOBILE

Current Provider?

How many lines do you have in your plan?

How much high-speed data does your plan include?

How much is your monthly plan?

EXCLUDE device fees/other charges

Do you owe money on your devices?

(Installment Fee)

Are you open to explore our options?

INTERNET

What type of internet connection do you currently have?

Internet Speed?

ex: 300 Mbps, 500 Mbps, 1000 Mbps, etc.

Current provider?

Bundled with:

Primary Internet Activity:

Other

How much is your monthly bill?

When does your contract(s) expire?

Are you open to explore our options?

TELEVISION

Do you currently pay for TV?

Current provider?

Is your service

How much is your monthly bill?

When does your contract(s) expire?

Are you open to explore our options?