JOIN A MEETING     CONTACT     FORMS     ABOUT     HOME  
"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
Long-Term Quote
Please use this form to submit a quote request. A licensed representative from our company will contact you about your request.


Proposed Insured
Spouse
* First Name
* Last Name
Email Address
*Birthday (mm/dd/yyyy)
*Street
*City
*State
*Zip Code
*Telephone
Any Hospitalizations in past 10 years?
Medications
Tobacco User?
If Yes, how long?
Please specify for each if either have been diagnosed/treated in the past 10 years so we can provide an accurate quote.
Alcoholism
Cerebral Vascular Disease
Lou Gehrig's Disease
Emphysema
Alzheimer's
Spine/Back Disorder
Aneurysm
Heart Attack
Cancer
Neurogenic Bladder
Confusion/ Disorientation
Organic Brain Syndrome
Congestive Heart Failure
Organ Transplant
Dementia
Carotid Artery Disease
Diabetes
Osteoporosis w/ Fractures
Depression
Parkinson's Disease
Lupus
Peripheral Neuropathy
Kidney Failure
Senility
Memory Loss
Stroke
Epilepsy
Ulcerative Colitis
Multiple Sclerosis
Macular Degeneration
Arthritis



Agent Name
Thank you. Your quote request has been submitted.
Name
Telephone
Email
Thank you. Your quote request has been submitted.
Please fill out the Required Fields.
Major Carriers
<
>