Auto Insurance Quote Form

If you would like to receive a quote for coverage on your personal auto, please fill out the form below.

Once you hit the "Submit" button, you will receive confirmation by email that your form was submitted. However, if we have not responded to your request within 24 hours, please telephone us to confirm that your Request for a Quote was received.

You may also reach us by telephone, during normal business hours, to request an Auto Insurance quote.

Fields marked with an * are required.
PRIMARY DRIVER INFORMATION:

*Name of Primary Driver

*Drivers License Number

*Date of Birth

 / / (mm/dd/yyyy)

Years Licensed

*Marital Status
Single
Married

Occupation

*E-Mail

*Phone Number

 --

Current Insurance Company

*Policy Renewal Date

 / / (mm/dd/yyyy)

*Any accident, violation, or suspension of license in the last 3 years for any of the above?
Yes
No

If yes, please explain.
ADDITIONAL DRIVER INFORMATION #1:

Name of Additional Driver

Drivers License Number

Date of Birth

 / / (mm/dd/yyyy)

Years Licensed

Marital Status
Single
Married

Occupation
ADDITIONAL DRIVER INFORMATION #2:

Name of Additional Driver

Drivers License Number

Date of Birth

 / / (mm/dd/yyyy)

Years Licensed

Marital Status
Single
Married

Occupation
Please provide information about the autos you would like covered.
AUTO #1:

*Year

*Make

*Model

Cost New

 $

*VIN

Driver Name

*Use
Pleasure
Business
AUTO #2:

*Year

*Make

*Model

Cost New

 $

*VIN

Driver Name

*Use
Pleasure
Business
AUTO #3:

*Year

*Make

*Model

Cost New

 $

*VIN

Driver Name

*Use
Pleasure
Business

*Comprehensive Deductible

 $

*Collision Deductible

 $

*Liability Limit

 $

*Please choose one or the other:
Full Tort
Limited Tort

Medical Expense Limit

 $

Wage Loss

 $

Funeral Expense

 $

Accidental Death Benefit

 $

Extraordinary Medical Benefit Limit

 $

*Uninsured/Underinsured Motorist Limit

 $

*Please choose one or the other:
Stacked
Unstacked

*Rental Reimbursement

 $

*Towing
Yes
No

Special Instructions

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Triangle Benefit Services • 128 Clairton Boulevard, Pittsburgh, PA 15236 • Phone 412-650-6500 • Fax 412-650-6505