About You:

Title:

Mr Miss Mrs Ms Dr

* First Name:

* Last Name:

* Denotes obligatory field

Address:

* Town

* Postcode

Telephone:

Mobile:

Email address:

About Your Home:

Are you a home owner?:

Please select... Yes No

Do you have a mortgage?:

Please select... Yes No

What household insurance do you currently have ?:

Please select... None Buildings Contents Building & Contents

When is your insurance renewal date ?:

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 32

Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Year 2006 2007 2008

About the Furness:

How long have you been a customer of the Furness?:

Please select... less than a year 1 - 2 years 3 - 4 years more than 5 years

Do you feel it is important that the Society treats its customers fairly?:

Please select... Yes Not Sure No

Since obtaining the products how do you rate the information that has been provided?

Please select... Superb Really Good Satisfactory It'll Do Don't Ask!

Have the products you have obtained from the Society met your expectations?

Please select... Yes No

How did you rate the information you received in respect of marketing and details of the products?

Please select... Superb Really Good Satisfactory It'll Do Don't Ask!

How would you rate the level of service you receive from the Furness?:

Please select... Superb Really Good Satisfactory It'll Do Don't Ask!