To provide you with excellent service we need your feedback. Please complete the following questionnaire and give us your opinions and comments. We look forward to servicing your insurance needs.


Agent Name
(Mandatory to qualify for the $250 Cash Drawing)
What type of agent are you?
(Check all those that apply)		 Career Agent
Independent Agent
Registered Rep
Professional Designations
What is your major line of business focus?
(Check those that apply) 		Traditional Life Insurance
Estate Planning
Business Insurance
Long Term Care
Disability Insurance
Fixed Annuities
Health Insurance
Do you have a secondary line of business?
(Check those that apply)		 Life insurance
Long Term Care
Disability Insurance
Annuities
Health Insurance
How many years have you been an insurance agent?
How many years have you done business with LifeBrokers? (CPS/Arizona) 
How many cases do you submit a year with LifeBrokers? (CPS/Arizona) 
What percentage of your business do you place with a brokerage agency?
During this past year have you done business with a brokerage agency other than LifeBrokers? (CPS/Arizona) YES NO
If the answer is YES approximately how many cases a year do you place with the other brokerage agency?
Below, is a list of factors you might use to select a brokerage agency, Rate each factor as to being Very Important, Important, Neutral or Not Important in your selection criteria. Place a check in the box.
Very Important Important Neutral Not Important
Products
Service
Compensation
Location
Sales and Marketing Ideas
Ease of Website
Communication between Producer and Brokerage
Impaired Risk Cases
Friendliness of Staff
Incentive Plans/Trips
Now that you have rated the criteria for a brokerage agency, please rate LifeBrokers on the same criteria as being Excellent, Above Average, Average, or Poor.
Exellent Above Average Average Poor
Products
Service
Compensation
Location
Sales and Marketing Ideas
Communication between Producer and Brokerage
Impaired Risk Cases
Friendliness of Staff
Incentive Plans/Trips
Now, if you have used another brokerage agency other than LifeBrokers in the last two years, please rate the other brokerage as better, worst, or the same compared to LifeBrokers on the following criteria.
Better Than
LifeBrokers		 Worse Than
LifeBrokers		 The Same as
LifeBrokers
Products
Service
Commissions
Office Location
Sales and Marketing Ideas
Ease of Website
Competency of Staff
Communication between Producer and Brokerage
Impaired Risk Cases
Good Communication
Gets my cases through on time
Effective Solving Problems
Offers/
Incentives/
Trips
Please tell us which brokerage agency you are comparing us with.
Regarding your case(s) at LifeBrokers, please rate the following factors in the management of your cases.  Rate these factors as Excellent, Above Average, Average, Below Average, Poor.
Excellent Above
Average		 Average Below
Average		 Poor
I have confidence in my case manager
Keeps me informed
Understands my cases
They do the best they can
Works hard on my behalf
Solves problems effectively
Gets my cases through in a reasonable time
Is Professional
I get the answers I need most of the time
Friendly and Personable
Overall I would rate my case managment as:
Did you know that LifeBrokers has an estate planning and business specialist who can help you with cases at no cost to you?      YES NO
Did you know that LifeBrokers has an incentive plan based on production? YES NO
In your opinion what are the strengths of LifeBrokers?
In your opinion what are the weaknesses of LifeBrokers?
If you have stopped using LifeBrokers in the past year could you please tell us why? (Answer only if you have stopped using LifeBrokers)
What could we do to get you to start placing your cases with LifeBrokers again?

If you need to update your contact information with LifeBrokers please complete below:
Name
Mailing Address
Office Phone
Cell Phone
E-Mail Address
...