Essential Services Survey

Individual Essential Services

Please fill out the information below so we can contact you with your results
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address (No P.O. Box)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Essential Services

If you own a business OR help make business decisions for your company, this part of the survey will help us to understand what options would be best for your business.
Are you the business owner or employee for the business?*

Business OwnerEmployeeOther
Contact Person*

First NameLast Name
Business Name*
Type of Business*
Contact's Phone Number*
Please enter a valid phone number.
Contact's Email*
example@example.com
Business Address (No P.O. Box)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who else will be involved in the decision making process?*

Life & Supplemental Health Insurance - Business

Please note that all insurance options do NOT cost the business anything. These benefits would be voluntary for employees and would save the business on payroll taxes.
Do you have Life Insurance or Supplemental Health Insurance for your employees?*

Life InsuranceSupplemental Health InsuranceNone of the Above
Would you be interested in saving on payroll taxes?*

YesNo
Would you be interested in providing more options for life and supplemental health benefits for your employees? (no cost to the business)*

YesNo

Health Care - Individual
Do you have Health Insurance?*

YesNo
How many members are in your plan?*
How much is your monthly payment?*
Are you interested in a free quote?*

YesNo
What is the Date of Birth of the oldest member in your household? *

MonthDayYear
Date
Number of Household members?*

Payment Processing - Business
Do you currently accept credit cards?*

YesNo
How do you accept payments?

Face to Face, in storeThrough company websiteOn the go, mobileManuel key entry
How many business locations do you have?*

Security & Automation - Business
Do you have a doorbell camera or smart business equipment?*

YesNo
Is it integrated with your Security system?

YesNoI do not have a Security System
If yes, who is your current provider?
eg., ADT, Brinks, VIVINT, etc...
If yes, when does your contract(s) expire?

MonthDayYear
Date
If yes, how much is your monthly bill?
Are you open to explore our business security options?*

YesNo
What is the best day and time to get a free quote from Vivint? (please make sure time zone is accurate)

Security & Automation - Individual
Do you have a doorbell camera or smart home equipment?*

YesNo
Is it integrated with your Security system?

YesNoI do not have a Security System
If yes, who is your current provider?
eg., ADT, Brinks, VIVINT, etc...
If yes, when does your contract(s) expire?

MonthDayYear
Date
If yes, how much is your monthly bill?
Are you open to explore our security options?*

YesNo
What is the best day and time to get a free quote from Vivint? (please make sure time zone is accurate)

Internet - Individual
What type of internet connection do you currently have?*

FiberCableNo Internet Connection
Current Provider?
Internet Speed?
ex: 300 Mbps, 500 Mbps, 1000 Mbps, etc.
Bundled with:

TelevisionPhoneMobileNone
How much is your monthly bill?

Digital Phone & Cloud Solutions - Business

Take communication to the Next Level.
Do you have business landlines?*

YesNo
Are you open to explore our Digital Phone options?*

YesNo

Individual Essential Services