Home Insurance Quote Form

If you would like to receive a quote for coverage on your home, 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 a
Home Insurance quote.

Fields marked with an * are required.
PRIMARY HOMEOWNER'S INFORMATION:

*Name

*Address

*City

State

*Zip Code

County

*Number where you can be reached

 --

*Do you own or rent?
Own
Rent

Marital Status
Single
Married

Occupation

*E-Mail

*Type of Residence

Single Family

Townhouse

Condo

 Mobile Home Apartment

*Year Built

*Type of Construction

*Number of Stories

Number of Families

Limit of Insurance Needed on Residence (does not apply for renters)

 $

If Renting, Limit of Insurance Needed for Personal Property

 $

*Liability Limit

 $

*Medical Expense Limit

 $

*Deductible

 $

*Distance to Closest Fire Department

 miles

*Distance to Closest Fire Hydrant

 feet

*Number of Smoke Detectors

*Any Alarm System?
Fire
Burglar
Both
None

*Any Pools?
In Ground
Above Ground
None

If Yes, is it Fenced?
Yes
No

*Do You Have Pets?
Yes
No

Please List any Pets and if You Have a Dog, Please Include Breed:

Currrent Insurance Company

*Policy Renewal Date

 / / (mm/dd/yyyy)

Any Items that You Would Like Scheduled, Please List Along with Value

*Any Claims in the Past 3 Years?
Yes
No

If Yes, Please Explain

Special Instructions

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