Health insurance quote form template
This five-step health insurance quote form asks the current coverage status, the type of plan, when cover should start and any notes, followed by the contact details. Clone it into your Growform account and rename the plan types.
What the form asks, step by step
The questions follow the order an agent uses to open a health insurance conversation. None of them asks for medical details, which keeps the form comfortable to complete on a public website.
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Step 1: “What is your current health insurance status?”
Insured, uninsured or switching tells the agent which conversation to have first.
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Step 2: “What type of coverage are you interested in?”
Individual, family, senior and student plans come from different carriers and price tables.
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Step 3: “How soon do you need your new insurance plan to start?”
Anyone who needs cover immediately should be called back the same day.
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Step 4: More information
A free-text box lets the applicant mention dependents, doctors or current premiums.
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Step 5: “How shall we contact you?”
Name, email and phone come last.
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After submitting
The thank-you screen that follows can be reworded to explain when a licensed agent will call with plan options.
Who it’s for
Independent health insurance agents, brokerages and marketplace lead generators use this template on quote pages. It is a short health insurance questionnaire that tells you who is uninsured, who is shopping for a family plan and who needs coverage to start now. Those three answers decide which carrier to quote and how quickly to call. Detailed eligibility questions are left for the conversation, where the agent can ask them properly. Brokers selling supplemental policies can also look at the group health insurance template.
Why this structure converts
- The first question lets the visitor describe their situation in one tap, whether they have cover or not.
- “Just looking” is an honest option on the timing step, and it keeps browsers in the form instead of on the back button.
- Nothing medical is asked, so the form feels like a request for prices rather than an application.
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Make it yours
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Ask for ZIP code and age
Premiums depend on location and age. Add a ZIP code field and an age band before the contact step so the first quote is accurate.
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Add a consent checkbox
If you call leads by phone, add a consent checkbox to the last step and turn on TrustedForm or Jornaya for proof.
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Branch on coverage type
Use conditional logic to ask how many dependents only when the visitor chooses a family plan.
Send every lead where your team works
Frequently asked questions
Is this a health insurance form for enrollment?
No. It is a quote request that qualifies the lead. Enrollment and the full health insurance form are completed with the carrier once the applicant chooses a plan.
What makes a good health insurance quote form?
It asks the questions that change the price, such as coverage type, start date, location and age, and nothing an applicant would hesitate to share online.
Which insurance CRMs does it connect to?
Growform works with EZLynx, AgencyZoom, HubSpot and Salesforce, and it can post each lead to Slack for fast follow-up.
What happens next?
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Step 1: Clone this form template
Clone this template into your Growform account (create one first if you don’t already have one). -
Step 2: Edit your form
Get creative and adjust your form's theme options, questions or layout in the Growform form builder. -
Step 3: Share or embed your form
Share a link to your form, or embed it in your existing website. Receive new submissions by email or send them to 7,000+ apps via Zapier.
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