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Pricing

Insurance Quote · Popular

Get Your Auto Insurance Premium Quote Fast

Collect applicant, vehicle, and driving history details to generate accurate auto insurance policy coverage and premium quotes online.

Use This Template Free Preview

Frost theme

formbuilder.ai/f/auto-insurance-policy-coverage-premium-quote-request-form

Auto Insurance Policy Coverage & Premium Quote Request Form

Full Name

· · ·

Email Address

· · ·

Phone Number

· · ·

Submit

The Auto Insurance Policy Coverage & Premium Quote Request Form makes it easy for insurance providers and brokers to gather all the essential information needed to generate accurate quotes for prospective policyholders. From applicant details and vehicle specifications to driving history, this form covers every data point that influences premium calculations.

Designed for insurance agencies, independent brokers, and financial services firms, this template streamlines the quoting process by digitizing data collection. Applicants can submit their full name, contact information, vehicle year, make, model, VIN, estimated annual mileage, and at-fault accident history — all in one convenient online form.

By using this ready-to-use template, insurers can reduce manual data entry, minimize errors, and respond to quote requests faster. Customize the form to match your branding, add conditional logic for multi-vehicle households, and integrate with your CRM or quoting software for a seamless end-to-end workflow.

4 Pages

26 Questions

~9min To complete

Free No credit card needed

Field types Dropdown ×4 number ×4 Short Text ×3 Yes / No ×2 File Upload ×2 Full Name Email Phone Date Address Single Choice Multiple Choice Priority Selection Long Text termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Personal Information 7 questions

Applicant Details

1 Full Name * Full Name

2 Email Address * Email

3 Phone Number * Phone

4 Date of Birth * Date

5 Residential Address * Address

6 Marital Status * Dropdown

7 Do you currently have auto insurance? * Yes / No

Page 2 Vehicle Information 11 questions

Vehicle Details

Please provide accurate details about the vehicle(s) you wish to insure. This information directly affects your premium quote.

1 Vehicle Year * number

2 Vehicle Make * Short Text

3 Vehicle Model * Short Text

4 VIN (Vehicle Identification Number) Short Text

5 Vehicle Usage * Dropdown

6 Estimated Annual Mileage * number

7 Is the vehicle financed or leased? * Single Choice

Driving History

8 Years of Driving Experience * Dropdown

9 Number of At-Fault Accidents in the Last 5 Years * number

10 Number of Moving Violations/Tickets in the Last 3 Years * number

11 Have you had any DUI/DWI convictions in the last 7 years? * Yes / No

Page 3 Coverage Preferences 4 questions

Desired Coverage Options

Select the types of coverage and limits you are interested in. Our agent will tailor the final quote based on your selections.

1 Coverage Types Requested * Multiple Choice

2 Preferred Deductible Amount * Dropdown

3 How soon do you need coverage? * Priority Selection

4 Any additional coverage needs or special circumstances we should know about? Long Text

Page 4 Review & Consent 4 questions

Review & Authorization

By submitting this form, you authorize us to use the information provided to generate an accurate insurance premium quote. The quote is not a binding agreement and is subject to verification of the details provided.

1 Upload a copy of your current insurance declaration page (if applicable) File Upload

2 Upload your driver's license (front) File Upload

3 I confirm that the information provided is accurate and complete to the best of my knowledge. I consent to being contacted regarding my quote request. * termsandconditions

4 Applicant Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.