Customer Information Form

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Customer Information Form
Please print, Thank You
First:
Last:
M:
Date:
________/_________/_________
Address:
City:
State:
Zip:
Vehicle Year:
Make:
Model:
Color:
Home Phone:
Work Phone:
Cellular Phone:
Email:
Insurance Company:
Did they recommend us?
Would you prefer to have your car repaired at our repair center?
How would you like to be communicated with while your vehicle is in for repairs?
Email
Cellular Phone
Text
Other _________________
1.How did you hear about our
5. Who’s paying for the repairs?
Additional Notes:
repair center?
o Your insurance company
o Repeat Customer
o Their insurance company
o Customer Referral
o I’m paying for the repairs
Referred by:____________
Myself
o Agent Referral
Referred by:____________
o Radio Ad
6. Do you need assistance in
o Driving By
Processing your insurance claim?
o Building Sign
o YES
o Yellow Pages
o NO
o Car Dealership
o Website
o Other
7. Do you have an estimate already
________________
Prepared by the insurance
2. Have you seen our newspaper
Company?
ad?
o YES
o YES
o NO
o NO
3. Have you seen our yellow page
ad?
o YES
o NO
4. Have you seen our website?
o YES
o NO

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Parent category: Business
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