# 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.

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.

Canonical: https://reuily.com/templates/insurance-quote-form
Use this template: https://reuily.com/form/from-template/insurance-quote-form
Collections: Marketing & Sales, Professional Services, Finance & Insurance
Last updated: 2026-10-24

## Questions

- Question 1: What's your full name? (Short Text, required)
- Question 2: What's your email address? (Email, required)
- Question 3: What's your phone number? (Phone, required)
- Question 4: What's your ZIP code? (Short Text, required)
- Question 5: Which coverage do you need a quote for? (Multiple Choice, required). Options: Auto; Home or renters; Life; Health; Business; Something else
- Question 6: Do you have insurance for this today? (Single Choice, required). Options: Yes, and it renews within 30 days; Yes, it renews later; No, I need new coverage
- Question 7: When do you need coverage to start? (Single Choice, required). Options: Right away; Within a month; Just comparing prices
- Question 8: How would you like us to reach you? (Single Choice, required). Options: Phone call; Text; Email
- Question 9: Anything else we should know? (Long Text, optional)

## 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

## 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.