Employee Initals
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Client Account #
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Time Spend on A/C
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Client Zip Code
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Aside price, what changes did we make to this customer's bills or what does the customer neet to know about the changes? Be specific, as this will be the additional informaiton on the bill.
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All below fields on this page is autofilled.
Client's Name
First Name
Last Name
Sex
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Male
Female
Type of Client (Personal, business, or nonprofit)
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Client's type of employment.
Is the client currently in college?
Yes
No
Is the client an AARP Member?
Yes
No
Is the client military/ veteran?
Yes
Not military
Birth Date
Preferred method of contact
*
Please identify the bills you are sending us
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Bundle: Internet + TV + Landline
Bundle: Internet + TV
Bundle: Internet + Landline
Bundle: TV + Landline
Internet (Non-bundled package)
Landline (Non-bundled package)
TV (Non-bundled package)
Cell Phone
Gym Membership
Alarm & Security / Home Automation
Trash
Satellite Radio
Other(s)
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Bundle: Internet + TV + Landline
Bundle: Internet + TV
Estimate how long have you been with this provider.
Name of Provider
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Duration of Provider call
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minutes
Date to follow up to renew discount
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-
Month
-
Day
Year
Date Picker Icon
Original Internet Speed
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Megabytes
New Internet Speed
Megabytes
Original # of Channels
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New # of Channels
Original Price
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Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Total Savings ($)
*
Savings (%)
*
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Bundle: Internet + Landline/VoIP
Internet (Not bundled Package)
Name of Provider
*
Estimate how long have you been with this internet provider.
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Provider call duration
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original Internet Speed
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Megabytes
New Internet Speed
Megabytes
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto-calculated
Total Savings ($)
*
Auto-calculated
Savings (%)
*
Auto-calculated
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Bundle: TV + Landline/VoIP
TV (Not part of a bundled package)
Name of Provider
*
Estimate how long have you been with your TV provider.
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Provider call duration
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original # of Channels
*
New # of Channels
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto-calculated
Total Savings ($)
*
Auto-calculated
Savings (%)
*
Auto-calculated
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Landline/ VoIP (Not part of a bundled package)
Name of Provider
*
Estimate how long have you been with your phone provider.
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Provider call duration
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto-Calculated
Total Savings ($)
*
Auto-Calculated
Savings (%)
*
Auto-Calculated
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Cell Phone
Name of Provider
*
Estimate how long have you been with your cell phone provider.
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill.
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Duration of call with Provider
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original data plan
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Gigabytes
New data plan
*
Gigabytes
Original Minutes plan
*
Minutes
New Minutes plan
*
Minutes
Original Text plan
*
Texts
New Text plan
*
Texts
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto-Calculated
Total Savings ($)
*
Auto-Calculated
Savings (%)
*
Auto-Calculated
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Gym Membership
Name of Provider
*
Estimate how long have you been with your gym.
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Duration of call with Provider
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto-Calculated
Total Savings ($)
*
Auto-Calculated
Savings (%)
*
Auto-Calculated
Back
Next
Home Security/ Home Automation
Name of Provider
*
Estimate how long have you been with your provider?
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill.
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
The customer has which or both services?
*
Security
Home Automation
Duration of call with Provider
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto-Calculated
Total Savings ($)
*
Auto-Calculated
Savings (%)
*
Auto-Calculated
Back
Next
Trash
Name of Provider
*
Estimate how long have you been with your trash provider
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Duration of call with Provider
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto-Calculated
Total Savings ($)
*
Auto-Calculated
Savings (%)
*
Auto-Calculated
Back
Next
Satellite Radio
Name of Provider
*
Estimate how long have you been with your satellite radio provider.
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill.
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Duration of call with Provider
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original # of Channels
*
New # of Channels
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto-Calculated
Total Savings ($)
*
Auto-Calculated
Savings (%)
*
Auto-Calculated
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Other Bills
Name of Provider
*
Estimate how long have you been with each of these other service providers.
*
Check if the client had a problem with this provider
Yes, client had a probelm with this provider
Check if we did NOT save money on this bill.
Our negotiations did not save money
We have not yet negotiated this bill
What type of verification did the provider require?
*
Client had to confirm over the phone
We just had to provide the account password/ passcode
There was no verification
Duration of call with Provider
*
minutes
Date to follow up to renew discount
*
-
Month
-
Day
Year
Date Picker Icon
Original Price
*
Dollars per pay period
Savings per pay period
*
Dollars
Duration of Savings
*
Pay Periods
Negotiated Price
*
Auto Calculated
Total Savings ($)
*
Auto Calculated
Savings (%)
*
Auto Calculated
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This is the total client savings we have achieved.
Is the client's total savings over $100?
Yes
No
Submit
Should be Empty: