Insurance Study

Name

Phone

E-Mail

State

Gender

Age

	Yes	No
1) A marketing research firm or department	1) A marketing research firm or department Yes	1) A marketing research firm or department No
2) An advertising agency or department	2) An advertising agency or department Yes	2) An advertising agency or department No
3) Public relations firm or department	3) Public relations firm or department Yes	3) Public relations firm or department No
4) Financial services firm like a bank, brokerage firm, mutual fund, or insurance company	4) Financial services firm like a bank, brokerage firm, mutual fund, or insurance company Yes	4) Financial services firm like a bank, brokerage firm, mutual fund, or insurance company No
5) Newspaper or magazine, print or online	5) Newspaper or magazine, print or online Yes	5) Newspaper or magazine, print or online No

Are the primary decision-maker for your household

Share equally with someone else in making financial and insurance decisions

Are minimally or not involved in financial and insurance decisions

Own

Rent

Other (please specify)

1. Auto

2. Home/Condo

3. Renter’s

4. Life

5. Health

6. Pet

7. Umbrella

8. Motorcycle

9. RV

10. Boat

11. None of these