Insurance Quote Request — Kickoff intake form (public) for Insurance. Embeddable version — a transparent, chrome-free form that floats over your own website design (pair with the standalone version for a hosted page).

Tell us what you’d like covered and when. A few quick details get us started — this is a request for a quote, not a binding of coverage, and we never ask for Social Security or policy numbers here.

What it collects (by section):

• About you — First name [short text]; Last name [short text]; Email address [short text].
• What you’d like covered — Lines of Interest (insurance) [multi-select: Auto (personal) / Homeowners / Renters / Umbrella (personal) / Life / …]; Policy Intent [dropdown: New / Renewal review / Remarketing]; Target Effective Date [date].
• Your situation — Current Carrier(s) (names only) [long text] (conditional); Servicing Preference [dropdown: Agent-managed / Self-service portal / Mixed]; Cross-Sell Interests (insurance) [multi-select: Umbrella / Flood / Earthquake / Cyber / Life / …].
• Anything else — Insurance Notes (client-specific) [long text].

Conditional logic (forks):

• WHEN Policy Intent is not New → show Current Carrier(s) (names only) (hidden by default until met).

Required: Email address, Lines of Interest (insurance) (kept low-friction).

Form type: Kickoff intake (in), public. Niche: Insurance. Deployment: embed.

Best for / surface when: An independent insurance agency taking quote requests — capturing the lines of coverage a prospect wants, their intent (new, renewal, or remarketing), target effective date, and current carriers, without ever asking for policy or account numbers.