Insurance Agent/Broker Survey
Exit this survey
1.
PCIP would like to know how we can help you. Your answers to the following questions will give us a better idea of how we can best serve you as an insurance agent or broker.
*
1
. Please enter the date.
MM
DD
YYYY
What date did you complete this survey?
Please enter the date. What date did you complete this survey? Month
/
Day
/
Year
2
. How would you prefer to receive information and program updates about PCIP? (check all that apply)
How would you prefer to receive information and program updates about PCIP? (check all that apply)
Email Messages
Mailings, such as letters
Tweets from Twitter
PCIP Website
3
. Would you be interested in the following? (check all that apply)
Would you be interested in the following? (check all that apply)
An Informational Guide to help fill out the application
Informational session on eligibility and enrollment via Conference Call
Informational session on eligibility and enrollment via Webinar
4
. If the public needs assistance in filling out the application would you like your insurance business information displayed on the PCIP Website?
If the public needs assistance in filling out the application would you like your insurance business information displayed on the PCIP Website?
Yes
No
If yes, Please enter your insurance business information here.
5
. Insurance business information:
Insurance business information:
Business Name
Contact Person’s Name
Business Street Address, City, CA, Zip
County
Business Phone
Business Email
Hours of business operation
Language capability
6
. Do you have any suggestions or comments to share about the application process?
Do you have any suggestions or comments to share about the application process?
7
. Would you be interested in receiving the following PCIP marketing materials? (check all that apply)
Would you be interested in receiving the following PCIP marketing materials? (check all that apply)
Poster
Brochure
Flyer
Other (please specify)
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