Customer Satisfaction Survey

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name Required
Last Name Required
ZIP / Postal Code Required
E-Mail Address Required
How would you rate our service:
In Reviewing All of Your Insurance Needs Optional	1 2 3 4 5
In Handling Changes Optional	1 2 3 4 5
If you've visited our website, www.clhins.com, to get information, request a quote, or join our newsletter:
How was your experience? Optional	1 2 3 4 5
If you use Facebook or Twitter:
Are Our Profiles Useful? Optional	1 2 3 4 5
Overall Satisfaction with CLH, Your Insurance Connection Optional	1 2 3 4 5
Based on the Experience You've Had, Would You Refer CLH to Friends and Family? Optional	Yes No
Additional Comments: Optional
Submission Validation Required	Enter the Validation Code from above.

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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