Client Questionnaire – Efficient Automation

Customer Flow (#16)

First Name

Last Name

ID Number

Home Number

Cell Number

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Broker Details

Hollard Policy Number

Billing Address

Mark as Same as Physical

Billing Address Details

Address Line 1

Address Line 2

City

State

Zip Code

Country

Is your property Single Phase or Three Phase?

Single Phase

Three Phase

I don’t know