Business Medical Quote Form

Business Medical Quote Form

If you would like to receive a quote for medical coverage for your business, please fill out the forms 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 a
Business Medical quote.

Fields marked with an * are required.

Individual Medical

Business Medical

Business Liability

Auto Insurance

Home Insurance

PRIMARY BUSINESSOWNER'S INFORMATION:
*Name
*Business Name
*Type of Business
Address
City
State
Zip Code
*E-Mail
*Work Phone	--
Best Time to Contact You	am pm

PRESENT HEALTH INSURANCE INFORMATION:
Current Health Insurance Carrier
Current Workers' Comp Carrier
Current Health Insurance Plan
SIC Code

Employee Name	Birthdate (mm/dd/yyyy)	Male/ Female	Single/ Married	Number of Children	Home Zip Code	Salary/ Hourly Rate*	Job Description	Waiving Coverage
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*Please complete if interested in group life or disability quotes.

Please check one of the following coverages you are interested in:
Health Insurance	Dental Insurance	Vision Insurance
Group Disability Insurance	Group Life Insurance	Workers' Comp

Home I About TBS I Products & Services I Client Center I Contact Us

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