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Health Insurance

We do it all for you! Full and flexible health care coverage for you and your family. In addition to group coverage for all sizes & types of business - starting at as little as 2 employees up to large groups.

• All Major Medical Plans
• HMO Plans
• Small Business Plans
• Group Plans
• Hospital Indemnity Programs
• Medicare Supplement Plans
• Self Funded Insurance - for large groups of 25 or more employees
• UPMC Plans

Call us at 1-800-919-2682 or use the form below to set up a no charge consultation.

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Health Insurance Quote Request

Please complete the following form as completely as possible and submit it to our office. We will contact you after we have received and reviewed your information.

I am looking for information on:

Individual Group

Primary Adult Information

First Name	**REQUIRED
Last Name	**REQUIRED
Email Address	**REQUIRED
Phone Number	**REQUIRED
Gender:	Male Female
HOME Street Address	**REQUIRED
HOME City	**REQUIRED
HOME State	Armed Forces AmericasAlbertaArmed Forces CanadaArmed Forces EuropeArmed Forces Middle EastAlaskaAlabamaArmed Forces PacificArkansasArizonaBritish ColumbiaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsManitobaMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNew BrunswickNorth CarolinaNorth DakotaNebraskaNewfoundlandNew HampshireNew JerseyNew MexicoNova ScotiaNunavutNorthwest TerritoriesNevadaNew YorkOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSouth CarolinaSouth DakotaSaskatchewanTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingYukon Territory **REQUIRED
HOME ZIP CODE	**REQUIRED
Date of Birth:	(mm/dd/yyyy)
Smoker:	No Yes
Health issues, please list:

Secondary Adult / Spouse Information

First Name
Last Name
Gender:	Male Female
Date of Birth:	(mm/dd/yyyy)
Smoker:	No Yes
Health issues, please list:

Dependent Information

# of children to be covered	1 2 3 4 5 6 7 8 9 10 11 12
Children's ages (comma separated please):