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Contact Information
First Name : 
Last Name : 
Phone : 
Email Address : 
 
 
 
What type of service is being requested?
 
 
 
Is this person...
 
a current customer?
 
a prospect that we've talked to in the past?
 
a lead not previously contacted?
 
a Farmers company person?
 
an outside company person?
 
Other
 
 
 
 
Describe the issue.
   
 
 
 
What is the contact's expectation regarding a follow-up action?
 
Phone call?
 
Appointment at office?
 
Appointment at home?
 
Correspondence?
 
Documentation?
 
Other
 

 
 
 
What date does the contact expect follow-up?
MonthDayYear
  
 
 
 
What time of day works best?
Hrs.Mins.AM/PM