Cut the phone tag and collect every detail you need for an accurate health insurance quote in one clean form. This template captures coverage type, household size, tobacco use, pre-existing conditions, budget range, and preferred deductible — so your agents can prepare competitive quotes before the first conversation. More information upfront means faster quotes and happier prospects.
Free for non-commercial projects, with unlimited forms and responses.
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A health insurance quote request form is the first step in converting a curious prospect into a covered client. Most people seeking health coverage don't know exactly what plan they need — they know their budget, their family size, and their health situation. A great intake form meets them where they are and captures the essential data your agents need to come back with options that actually fit.
This template is built around the information that drives quote accuracy: coverage type, number of people, tobacco status, pre-existing conditions, deductible preference, and budget range. Each question is deliberately framed to be non-threatening — prospects who feel judged by health questions often abandon forms before submitting. The language here is clinical but neutral, maximizing completion rates without sacrificing the data quality your underwriting team needs.
formformform makes this form easy to deploy across any channel. Embed it on your agency website, share the link via email campaigns, or use it as your standard intake process at health fairs and community events. Every submission is stored in your dashboard and triggers an instant email notification so your team can follow up within minutes — a significant competitive advantage in a market where speed-to-contact determines close rates.
Use your own copy to change labels, remove questions and add the details you need. Try the preview alongside this guide to see what respondents will be asked.
Review the starting questions and choices. You can change them in your own copy.
Jane Smith
jane@email.com
(555) 123-4567
90210
2
Specific medications, preferred doctors, or coverage priorities.
Suggested uses, and why this starting point can help. Adapt the questions to your own process.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “ZIP Code” in particular and adapt it to the detail you need.
Collects applicant age, zip code, household income, tobacco use, current health status, and coverage start date for ACA marketplace quotes
Get a useful brief before the first conversation. Written context helps you assess fit, prepare questions and decide what to discuss next. Review “Total Number of People to Cover” in particular and adapt it to the detail you need.
Get a useful brief before the first conversation. Written context helps you assess fit, prepare questions and decide what to discuss next. Review “Type of Coverage Needed” in particular and adapt it to the detail you need.
Collect a consistent starting point for review, so the next conversation can focus on suitability and missing details rather than repeating basic questions. Review “Desired Coverage Start Date” in particular and adapt it to the detail you need.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Do you or any applicant use tobacco products?” in particular and adapt it to the detail you need.
Use this as a starting point when you need the same essential information from each person. Review the questions against your process before sharing your copy. Review “Are there any pre-existing medical conditions?” in particular and adapt it to the detail you need.
Click 'Use this template' to load the health insurance quote request form into your formformform account — all fields are pre-configured.
Customize the coverage type dropdown to match the plan categories your agency actually offers — remove options you don't write and add any niche products specific to your market.
Adjust the budget range options to reflect realistic premiums in your target geography — urban markets may need higher tiers than rural ones.
Set your notification email to your sales inbox or CRM webhook so every lead reaches your team immediately.
Add your agency logo and brand colors using the form appearance settings to build trust with prospective clients.
Embed the form on your website's quote landing page or share the direct link in your email and social media campaigns.
many prospects are responding to a qualifying life event (job loss, marriage, new baby) with hard enrollment deadlines; knowing this urgency helps you prioritize follow-up.
use clinical language ('pre-existing medical conditions') rather than alarming terms. Judgmental framing causes form abandonment before you get the lead.
some clients want an instant email summary, others prefer a phone consultation; giving them the choice improves response rates and sets the right expectations.
offer them as distinct coverage types rather than checkboxes under 'health,' since they require different quote workflows and are often purchased separately.
ZIP code is enough for geographic rating and is much less invasive to collect at the top-of-funnel stage before you've established trust.
even a single field asking about specific prescriptions helps agents filter for plans with the right formularies before the first call.
insurance is a competitive market and prospect intent degrades quickly; configure your formformform notifications to go directly to a monitored sales inbox.
Collects applicant age, zip code, household income, tobacco use, current health status, and coverage start date for ACA marketplace quotes
Gathers family size, ages of dependents, preferred doctor network, prescription needs, and budget range for family plan quotes
Collects employee count, industry, contribution percentage, census data, and renewal date for employer-sponsored plan quotes
Gathers Medicare Part A/B enrollment status, current coverage gaps, prescription drug needs, and preferred benefits for Medigap plans
Collects coverage gap duration, COBRA expiration, pre-existing conditions, and budget for temporary coverage quotes
Gathers household size, routine vs. major dental needs, orthodontia requirements, and preferred dentist network for dental plan quotes
Collects glasses/contacts frequency, eye exam needs, current vision plan, and optical retailer preferences for vision coverage quotes
Gathers employment termination date, current plan details, qualifying event, and household members for COBRA cost calculation
Collects destination country, coverage duration, evacuation coverage needs, and worldwide vs. regional coverage for international plans
Gathers school name, enrollment status, parent plan exclusion reason, and campus health center access for student-specific plans
Collects age under 30 verification, minimal coverage understanding, emergency-only preferences, and HSA eligibility for low-premium/high-deductible plans
Gathers faith-based affiliation, sharing amount preferences, pre-existing condition disclosure, and cost-sharing model understanding for alternative coverage
formformform is a general-purpose form builder and does not sign Business Associate Agreements (BAAs). For collecting protected health information (PHI), consult with your compliance team about your specific obligations before use.
Yes. Every formformform form can be embedded on any website using an iframe code snippet, or you can share the direct form URL as a standalone link. Both options work on any platform including WordPress, Squarespace, and custom sites.
formformform sends an instant email notification with all submission details to the address you configure. You can also view and export all submissions from your dashboard at any time.
Yes. The coverage type dropdown in this template supports individual, family, group, Medicare, dental, vision, and other plan types. You can also create separate forms for each coverage type and link to the appropriate one from different pages on your website.
At minimum you need ZIP code, age(s), tobacco status, and desired coverage type. This template also captures household size, pre-existing conditions, budget preference, and deductible tolerance — all of which help agents recommend the most appropriate plan options.
The phone number field is optional by default to maximize completion rates, but you can make it required in the field settings if your workflow depends on phone follow-up. Consider using conditional messaging to explain why you're asking.
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