Employer Group Number
Employer Group Name
Date of Call		mm/dd/yyyy
Approximate Time of Call		h:mm am

What was the nature of your contact with us?
General Information    Problem Resolution    Technical Assistance
Claim Status/Benefit Verification    Other:

1= poor 10= excellent	1	2	3	4	5	6	7	8	9	10	No Comment
Staff was courteous and helpful.
Staff provided complete, accurate information to me.
A timely response was provided.
My overall experience was positive.
My issue or question was completely resolved.

Please indicate the name(s) of any staff person you spoke with:

Comments:

If you feel we fell short in meeting your service expectations,
please describe the situation including name of the staff person
involved and the date the incident occurred:

As a result of your experience with us, what service-related
improvements can you recommend?

Contact Information:
(Optional, but must be completed to be eligible for prize drawing)

Your Name:			City:
Email:			State:
Daytime Phone:	123-456-7890		Zip:
Street: