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<form id="survey" action="#" method="post" class="form-horizontal">
  <div class="form-group">
    <label for="review-summary" class="col-sm-6 control-label">*Screen Name</label>
    <div class="col-sm-6">
      <input class="form-control" id="author" name="Author" size="30" type="text" value="Mike">
      <span class="help-block">Use your first name or a handle.</span>
      <span id="author-required" class="required-field" style="display: none;">Enter a Screen Name</span>
    </div>
  </div>
  <div class="form-group">
    <label for="SurveyQuestions[0].Rating" class="col-sm-6 control-label">*How would you rate your overall experience?</label>
    <div class="col-sm-6">
      <div id="star-cont-overall" class="star-cont" style="padding-bottom: 3px;">
        <div class="ui-stars-star"><a title="Awful">1</a></div>
        <div class="ui-stars-star"><a title="Below Average">2</a></div>
        <div class="ui-stars-star"><a title="Average">3</a></div>
        <div class="ui-stars-star"><a title="Above Average">4</a></div>
        <div class="ui-stars-star"><a title="Excellent">5</a></div><input type="hidden" name="SurveyQuestions[0].Rating" value="0" disabled="disabled">
      </div>
    </div>
    <div class="col-sm-6">
      <span id="star-required" class="required-field" style="display: none;">Choose a Star Rating</span>
      <span class="help-block colored-stars">For excellent service, click five stars.</span>
    </div>
  </div>
  <div class="form-group">
    <label for="review-summary" class="col-sm-6 control-label">*Review Title</label>
    <div class="col-sm-6">
      <input class="form-control" id="review-summary" name="ReviewSummary" size="30" type="text" value="">
      <span class="help-block">Enter a short summary, i.e. "Great Service, Awesome Price!"</span>
      <span id="title-required" class="required-field" style="display: none;">Enter a Review Title</span>
    </div>
  </div>
  <div class="form-group">
    <label for="review-text" class="col-sm-6 control-label">Share your opinion</label>
    <div class="col-sm-6">
      <textarea class="form-control" id="review-text" name="ReviewText" rows="4"></textarea>
    </div>
  </div>
  <div class="form-group">
    <label for="survey-rating-1" class="col-sm-6 control-label">How would you rate the quality of the service?</label>
    <div class="col-sm-6 star-cont">
      <input type="hidden" name="SurveyQuestions[1].CustomerSatisfactionSurveyQuestion_id" value="2">
      <div class="ui-stars-star"><a title="Awful">1</a></div>
      <div class="ui-stars-star"><a title="Below Average">2</a></div>
      <div class="ui-stars-star"><a title="Average">3</a></div>
      <div class="ui-stars-star"><a title="Above Average">4</a></div>
      <div class="ui-stars-star"><a title="Excellent">5</a></div><input type="hidden" name="SurveyQuestions[1].Rating" value="0" disabled="disabled">
    </div>
  </div>
  <div class="form-group">
    <label for="survey-rating-2" class="col-sm-6 control-label">How would you rate the cost / pricing of the service?</label>
    <div class="col-sm-6 star-cont">
      <input type="hidden" name="SurveyQuestions[2].CustomerSatisfactionSurveyQuestion_id" value="3">
      <div class="ui-stars-star"><a title="Awful">1</a></div>
      <div class="ui-stars-star"><a title="Below Average">2</a></div>
      <div class="ui-stars-star"><a title="Average">3</a></div>
      <div class="ui-stars-star"><a title="Above Average">4</a></div>
      <div class="ui-stars-star"><a title="Excellent">5</a></div><input type="hidden" name="SurveyQuestions[2].Rating" value="0" disabled="disabled">
    </div>
  </div>
  <div class="form-group">
    <label for="survey-rating-3" class="col-sm-6 control-label">How would you rate your experience with respect to convenience?</label>
    <div class="col-sm-6 star-cont">
      <input type="hidden" name="SurveyQuestions[3].CustomerSatisfactionSurveyQuestion_id" value="4">
      <div class="ui-stars-star"><a title="Awful">1</a></div>
      <div class="ui-stars-star"><a title="Below Average">2</a></div>
      <div class="ui-stars-star"><a title="Average">3</a></div>
      <div class="ui-stars-star"><a title="Above Average">4</a></div>
      <div class="ui-stars-star"><a title="Excellent">5</a></div><input type="hidden" name="SurveyQuestions[3].Rating" value="0" disabled="disabled">
    </div>
  </div>
  <div class="form-group">
    <div class="col-sm-6">
      <mark>* indicates a required field</mark>
    </div>
  </div>
  <div class="well well-sm">
    <div class="row">
      <div class="col-md-6"></div>
      <div class="col-md-6">
        <p style="font-size: 11px"> By clicking Submit Survey, you agree to the <a class="toc" href="#">Nearby Now Terms and Conditions</a>. </p>
        <input style="display: none" id="survey-submit" type="submit" class="btn btn-primary" value="Submit Survey">
        <a class="btn btn-primary" onclick="$('#survey-submit').trigger('click')">Submit Survey</a>
      </div>
    </div>
  </div>
</form>

Text Content

Mobile Version


CUSTOMER SATISFACTION SURVEY


Erica Henstein has invited you to share your recent experience with United Fire.



> We'd appreciate it if you could take the time to review us on one of our
> preferred review sites below:

--------------------------------------------------------------------------------




> We'd really love your feedback! Please fill out the brief survey below and
> click the submit button.


Approximate Location of Service. Nearby Now anonymously posts the results of
your survey in order to help other customers choose quality service pros. We
will not disclose your address or exact location.
*Screen Name
Use your first name or a handle. Enter a Screen Name
*How would you rate your overall experience?
1
2
3
4
5
Choose a Star Rating For excellent service, click five stars.
*Review Title
Enter a short summary, i.e. "Great Service, Awesome Price!" Enter a Review Title
Share your opinion

How would you rate the quality of the service?
1
2
3
4
5
How would you rate the cost / pricing of the service?
1
2
3
4
5
How would you rate your experience with respect to convenience?
1
2
3
4
5
* indicates a required field

By clicking Submit Survey, you agree to the Nearby Now Terms and Conditions.

Submit Survey
×

NEARBY NOW TERMS AND CONDITIONS

By clicking Submit Survey you grant permission to display your content publicly
on the web attributed to the Screen Name you enter with your review. Please do
not provide a review if you do not want to grant this permission. You also
warrant that:

 1. The review content you ARE providing is true and accurate.
 2. You ARE (or were) a client of the company you are completing the survey for
    and have direct, actual and first-hand experience with the product or
    service they offer.
 3. You ARE NOT being compensated or rewarded in any way for the completion of
    the survey and review content.
 4. You confirm you DO NOT work for or are related to the company in any way.
 5. You ARE NOT a competitor of the company you are completing the survey for.



If you have any questions or comments, please email us at support@nearbynow.co

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