Customer Questionnaire

First name
Last name
Address
City
State		Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
ZIP code
Service date
Invoice number
Service location
Technician name
Insurance company
Agent

Please rate our service in the following areas:

Courtesy of telephone customer service representative
Poor	Below Avg.	Good	Above Avg.	Excellent
Courtesy of Safelite® technician
Poor	Below Avg.	Good	Above Avg.	Excellent
Quality of work performed
Poor	Below Avg.	Good	Above Avg.	Excellent
Technician fulfilled the 5-Point Service Pledge
Poor	Below Avg.	Good	Above Avg.	Excellent
Overall service experience
Poor	Below Avg.	Good	Above Avg.	Excellent
Convenience of appointment
Poor	Below Avg.	Good	Above Avg.	Excellent

How quickly were we able to schedule your job?
Same day	Next day	2-4 days	4+ days

Did we schedule the job to meet your needs?
Yes     No

Would you recommend Safelite® to a friend?
Yes     No

If "no," why not


Additional comments


How did you find Safelite®?
  Insurance agent Mechanic referral Personal referral Radio ad TV ad Yellow Pages Billboard Store location Saw our van Internet Other