Feedback – Unity Insurance Broker

Customer Feedback Form

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Full Name

Phone

Email

Date / Time

How satisfied are you with

	Excellent	Good	Adequate	Poor
Quality of Service	ExcellentQuality of Service Excellent	GoodQuality of Service Good	AdequateQuality of Service Adequate	PoorQuality of Service Poor
Attitude of management	ExcellentAttitude of management Excellent	GoodAttitude of management Good	AdequateAttitude of management Adequate	PoorAttitude of management Poor
Response to complaints/concerns	ExcellentResponse to complaints/concerns Excellent	GoodResponse to complaints/concerns Good	AdequateResponse to complaints/concerns Adequate	PoorResponse to complaints/concerns Poor
Overall impression	ExcellentOverall impression Excellent	GoodOverall impression Good	AdequateOverall impression Adequate	PoorOverall impression Poor
Overall experience	ExcellentOverall experience Excellent	GoodOverall experience Good	AdequateOverall experience Adequate	PoorOverall experience Poor

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