Full Name:

Year, Make and Model of your vehicle:

Date you picked up your vehicle:

Select Month January February March April May June July August September October November December Select Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select Year 2017 2016 2015

Preferred method of contact:
Phone Email

Phone: Email:

Were you treated politely by all of our office staff?

Very Satisfied Satisfied Dissatisfied Very Dissatisfied

Were you kept adequately informed during the repair process?

Very Satisfied Satisfied Dissatisfied Very Dissatisfied

Did an adjuster do a walk around inspection with you when you picked up your vehicle?

Yes

No

Were you satisfied with the overall quality of the repair?

Was your vehicle ready when promised?

Were you satisfied with the way the insurance company handled your claim? (if applicable)

Very Satisfied Satisfied Dissatisfied Very Dissatisfied Not applicable

How likely is it that you would recommend us to your family and friends?

Very Likely Somewhat Likely Maybe Very Unlikely

Have you done business with us in the past?

Yes

No

What was your selection of our shop based on?

Please choose ALL that apply
Cost

Reputation

Location

Dealer Recommendation

Insurance Recommendation

Past Experience

Other (Please explain)

Would you like a company reprehensive to contact you?

Yes

No

Comments/ Suggestions: