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"Your One Stop Shop for Employee Benefits, Medicare, and Individual Coverages"

1.800.854.4099 | 724.458.7255

Individual Coverage

Choosing an affordable insurance plan is not as easy as it once was. There seem to be so many different options available and it can be overwhelming trying to decie where to begin.

Our expert staff is ready and able to assist you. If you have any questions, or if you would like more information on our services, please give us a call.

1.800.854.4099
Disability Insurance
Please use this form to submit a quote request. A licensed representative from our company will contact you about your request.


*REQUIRED FIELD
* First Name
* Last Name
Email Address
*Birthday (mm/dd/yyyy)
Gender
Street
City
State
Zip Code
*Telephone
Occupation
Government Employee
Adj. Gross Income If Self Employed
$
Gross Salary W-2
$
Monthly Salary
$
Existing DI Coverage
Plan Information
Base Amount
$
Benefit Period
Elimination Period



Additional Information
Please Indicate Any Special Health Issues

Include a Brief Summary of Job Duties


Agent Name
Name
Telephone
Email
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