JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
*CATASTROPHIC
OVER-DRAFT
BANK ACCOUNT
INSURANCE (Quarterly Open Enrollment)
To See If You *Qualify, Please Complete The Following:
Sign in to Google
to save your progress.
Learn more
A. With Your Bank, Do You Currently Have Standard Over-Draft Insurance?
Yes
No
Clear selection
JUST FOR THIS *EXAMPLE, THERE ARE ONLY (3) THREE FORMS OF INSURANCE
FOR THE SAKE OF *THIS (*EXAMPLE): If You Don't Own A Bank, The FDIC (Federal Deposit Insurance) Is Not Applicable To You
B. Are You Currently Involved In Any Litigation As A Result Of A Motor Vehicle Accident?
Yes
No
Clear selection
C. Name Of Your Current Primary Bank
Your answer
D. If You *Qualified For A Checkbook That Won’t Bounce, In the Event Of A *Catastrophic Accident, For Less Than 34¢ An Hour, At Virtually *No Cost To You, Providing That You *Qualify, Would You Take Advantage of It?
Yes
No
Clear selection
E. Which one would you prefer adding to your account?
Delux
High Option
Standard
Clear selection
F. Providing That You Qualify, If You Could Add This Insurance To Your Account, At Virtually *No Cost To You, Would You Take Advantage Of It?
Yes
No
Clear selection
G. Would You Agree It's A Win-Win? You Receive A Check If You Have An Accident Claim Or You Don't. Which Example Would You Prefer?
Example A
Example B
Example C
Clear selection
H. To See If You *Qualify, Please Complete The Following:
Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
Cell Phone
Your answer
Email Address
Your answer
Thank you for participating in our survey
CAPITOL INSURANCE GROUP The money-back people.
LifeWritesTheChecks.com
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Jorge Lopez Designs.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
