Private health insurance quote form template
This five-step private health insurance quote form asks the applicant’s age range, current health, any pre-existing condition and whether dependents need cover, followed by the contact details. Clone it into your Growform account and add a consent checkbox.
What the form asks, step by step
The four questions are the ones that most affect a health insurance price. Each is a single tap, so nobody needs documents to answer.
-
Step 1: “What’s your age range?”
Age bands from under 25 to 55 and above drive the premium.
-
Step 2: “What’s your current health status?”
Excellent to poor gives the broker an early view of underwriting.
-
Step 3: “Do you have a pre-existing condition?”
A yes prepares the broker for questions about exclusions and cover.
-
Step 4: “Are you looking for coverage for any dependents?”
Family cover changes the plans and the price you quote.
-
Step 5: “How shall we contact you?”
Name, email and phone come last.
-
After submitting
Applicants see the standard thank-you screen, and a broker would edit it to say when quotes will arrive.
Who it’s for
Health insurance brokers, comparison sites and lead generators use this template to capture people who want a private health insurance quote. The answers cover the pricing basics, so a broker can prepare options before the first call. It is a short private health insurance form for the inquiry stage and leaves the full medical declaration to the insurer. Brokers who also sell employer schemes can use the group health template.
Why this structure converts
- Age is asked as a band, which feels less personal than a date of birth.
- The health questions are simple yes-or-no and rating choices that take seconds.
- Contact details come after the applicant has described their situation and expects a relevant quote.
14-day free trial, no credit card
Make it yours
-
Add consent to contact
The template has no consent checkbox. Add one to the last step, and turn on TrustedForm if you pass leads to other brokers.
-
Ask about current cover
A question about existing insurance helps you spot switchers, who often need help understanding their exclusions.
-
Branch on dependents
Use conditional logic to ask how many dependents need cover when the applicant answers yes.
Send every lead where your team works
Frequently asked questions
What information does a private health insurance quote need?
Brokers usually start with age, general health, pre-existing conditions and who needs cover. This form asks those four before the contact details.
Is this an insurance application?
No. It is a quote request. The insurer’s application, with full medical questions, comes after the applicant chooses a plan.
Can leads go straight to my CRM?
Yes. Growform connects to AgencyZoom, HubSpot, Salesforce, Zoho CRM and ActiveCampaign.
What happens next?
-
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.
Start your free trial
Build multi-step forms just like this one. 14-day free trial, no credit card required.