SURVEY

SURVEY

During these crazy (COVID-19) times the world is overcoming, it is important we understand the need of services in our community. We want to thank you in advance for helping us with this survey.
Name & Last Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
GoodBadNeededNot Needed
Why do you believe that?*
What company do you have your Life Insurance with?*
Is it Permanent or Term?
Year Purchased:
Death Benefit:
What's your Premium/monthly payment?
YesNo
YesNo
YesNo
IRA401K403BAnnuitiesNone
$250,000$500,000$1,000,000$2,000,000
$50$75$100$200$400+
Have No PlanNot ComfortableComfortable
What's your monthly budget for Life Insurance?*
YesNo
YesNo
Home Owners: How much is your electric bill monthly?*
If you are not a home owner please type N/A
1-5 years old5-10 years old10 + years oldNew Roof Needed
YesNo
YesNo
YesNo
THANK YOU!

We wholeheartedly appreciate you helping us with your participation. This will help us understand the needs in the community.
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Should be Empty:

THANK YOU!