Individual Medical Quote Form

If you would like to receive a quote for individual medical coverage, 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 an Individual Medical quote.

Fields marked with an * are required.
PRIMARY INFORMATION:

*Name

*Spouse Name

Address

City

State

Zip Code

Country

*E-Mail

*Home Phone

 --

Fax Number

 --

Best Time to Contact You
am pm

Individual Date of Birth

 / / (mm/dd/yyyy)

Spouse Date of Birth

 / / (mm/dd/yyyy)

Current Health Insurance Carrier
Current Health Insurance Premium
Smoker/Non-Smoker Individual
Spouse
Body Weight Individual
Spouse
Received chiropractor assitance in the past 2 years or less Yes
No
Have any surgeries in the past 5 years or less Yes
No
Pregnant Yes
No
Prescriptions Yes
No
Please List Name and Age of Each Child Birthdate (mm/dd/yyyy) Male/Female
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Triangle Benefit Services • 128 Clairton Boulevard, Pittsburgh, PA 15236 • Phone 412-650-6500 • Fax 412-650-6505