Name
Required

E-Mail
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Type of Policy

Personal

Choose One Homeowners Dwelling Fire Automobile Flood Personal Umbrella Liability Recreational Vehicle Renters Motor Home and Travel Trailer Boat/Yacht Condominium Valuable Property Vintage and Antique Car Motorcycle Other

Business

Choose One Business Owners Equipment Floater Business Automobile Boiler Machinery Workers Compensation Business Interruption Commercial Umbrella Crime Commercial General Liability Glass Commercial Property Bonds Inland Marine Other

Date of Loss

Thank you for taking time out of your day to complete this Claims Survey. This information is very helpful for us in evaluating the level of service provided by both the insurance company, as well as Apple Valley Agency. Please be as open as possible with your comments.

 Yes     No     Did you receive prompt attention to your claim?

 Yes     No     Was the agency representative courteous and helpful?

 Yes     No     Was the insurance company representative courteous
                             and helpful?

On a scale of 1-5, with 5 being the best, how would you rate your claim service?

Additional Comments

Again, thank you for your comments.