Insurance Quote Request Form Template
A free insurance quote request form for agents and brokers. Prospects choose coverage and share key details, and lead mode marks ready buyers as hot leads.
Customize the pages and design to fit your needs.
About this template
Capture quote requests for auto, home, life, health and business insurance in one form. Lead mode marks prospects who are shopping now and whose policies renew soon as hot leads.
Common uses
- Independent insurance agents
- Brokers and agencies
- Landing pages for quote ads
Key features
- Coverage type and start date
- Current policy and renewal
- Hot lead tagging
What this template asks
What's your full name?
Short Text
What's your email address?
Email
What's your phone number?
Phone
What's your ZIP code?
Short Text
Which coverage do you need a quote for?
Multiple Choice · Auto, Home or renters, Life, Health, Business, Something else
Do you have insurance for this today?
Single Choice · Yes, and it renews within 30 days, Yes, it renews later, No, I need new coverage
When do you need coverage to start?
Single Choice · Right away, Within a month, Just comparing prices
How would you like us to reach you?
Single Choice · Phone call, Text, Email
Anything else we should know?
Long Text · Optional
How to use this template
Copy it
Select Use template and a copy opens in your workspace as an unpublished draft.
Make it yours
Edit any question or answer, choose a theme, and add your logo.
Share it
Publish, then send the link, show a QR code, or embed the form on your site. Responses arrive in Submissions.
Frequently asked questions
What should an insurance quote request form ask?
Contact details, ZIP code, which coverage they need, whether they're insured today and when it renews, when they need coverage to start and how to reach them.
How does lead mode help insurance agents?
Prospects who need coverage soon or whose policy renews within 30 days are marked hot, so agents call the most ready people first.
Can I send quote requests to my CRM?
Yes. Responses go to LeadConnector with tags and a lead level, or to any CRM through Google Sheets or a webhook.