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Income protection quote form template

This five-step income protection quote form asks employment status, age range, dependents and income bracket, followed by the contact details. You can clone it into your Growform account and add a smoking question.

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What the form asks, step by step

Income protection is priced on work, age and earnings, and the form asks for all three as quick choices. Dependents come in between because they explain the need.

  1. Step 1: “What’s your employment status?”

    Employed and self-employed applicants are quoted on different terms.

  2. Step 2: “What’s your age range?”

    Five age bands, from under 25 to 55 and over, set the premium range.

  3. Step 3: “Do you have any dependents?”

    A yes on dependents shows why the cover matters to this person.

  4. Step 4: “Which income bracket best describes you?”

    Income bands from under $25K to $100K and above size the benefit.

  5. Step 5: “How shall we contact you?”

    Name, email and phone come last.

  6. After submitting

    Rewrite the confirmation to say when quotes will arrive and from which insurers.

Who it’s for

Protection brokers, insurance agencies and lead generators use this template on income protection landing pages. Every income protection insurance quote request arrives with employment status, age, dependents and earnings, so a broker can see before calling whether cover is available and roughly what it will cost. Unemployed and retired visitors can be filtered or sent elsewhere automatically. Brokers who also sell life cover can use the life insurance quote form.

Why this structure converts

  • Employment status comes first because it decides whether cover is available at all.
  • Income is asked in bands, so nobody has to state an exact salary to get a quote.
  • The dependents question reminds the visitor why they started looking for cover.
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Make it yours

  • Filter ineligible visitors

    Use conditional logic to show a different message to visitors who answer unemployed or retired, since income protection normally requires earned income.

  • Add occupation and smoking

    Occupation class and smoking status both affect the price. Add them as button steps before the contact details.

  • Record consent

    Add a consent checkbox to the last step and turn on TrustedForm or Jornaya if leads are passed to other brokers.

Send every lead where your team works

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Frequently asked questions

What does an income protection quote need?

It needs employment status, age, income and usually occupation and smoking status. This template asks the first four, and you can add the others.

Can I use it in the UK and the US?

Yes. Change the currency on the income bands and rename the product to the term your market uses, such as disability insurance.

Can quote requests go into my CRM or dialer?

Yes. Growform sends them to FLG, Salesforce, HubSpot or VanillaSoft, and to your inbox by default.

What happens next?

  1. Step 1: Clone this form template

    Clone this template into your Growform account (create one first if you don’t already have one).

  2. Step 2: Edit your form

    Get creative and adjust your form's theme options, questions or layout in the Growform form builder.

  3. 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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