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Questionnaire template

Insurance Inquiry Form

Collects a prospective customer's contact details, cover needs, budget and current policy status to route an insurance enquiry.

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Other · Enquiry forms. All Other templates

Questions in this template

About You

  1. Tell us what cover you are looking for and one of our advisers will get back to you. It only takes a few minutes.

  2. What is your full name?

    Open answer

  3. What is your email address?

    Open answer

  4. What phone number can we reach you on?

    Open answer

  5. Who is the insurance for?

    Choose one:

    • Myself or my household
    • A business

The Cover You Need

  1. Which types of insurance are you interested in? Select all that apply.

    Choose any that apply:

    • Car
    • Home and contents
    • Life
    • Health
    • Travel
    • Business
    • Other

  2. Which other type of insurance?

    Condition: Shown when Other is selected

    Open answer

  3. How many vehicles would you like to insure?

    Condition: Shown when car insurance is selected

    A number from 1 to 20

  4. How many people should the life or health cover include?

    Condition: Shown when life or health insurance is selected

    A number from 1 to 20

  5. Roughly how much would you like to spend on premiums each month?

    Choose one from a list:

    • Under 50
    • 50 to 99
    • 100 to 199
    • 200 to 499
    • 500 or more
    • Not sure yet

  6. What matters most to you when choosing insurance?

    Choose one:

    • Price
    • How much is covered
    • How claims are handled
    • Flexible terms
    • Personal advice

Your Current Cover

  1. Do you already have insurance of this kind?

    Choose one:

    • Yes
    • No
    • Not sure

  2. When does your current policy end?

    Condition: Shown to people with an existing policy

    Choose one:

    • Within 1 month
    • In 1 to 3 months
    • In 3 to 6 months
    • In more than 6 months
    • Not sure

  3. When would you like new cover to begin?

    Choose one:

    • As soon as possible
    • Within a month
    • Within 3 months
    • I am just looking into options

Your Enquiry

  1. What would you like to ask us, or what help do you need?

    Open answer

  2. How would you prefer us to contact you?

    Choose one:

    • Email
    • Phone
    • Either

  3. Do you agree to us contacting you about this enquiry?

    Choose one:

    • Yes
    • No