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Home > Health > Individual Health Insurance Quote Request
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Individual Health Insurance Quote Request


Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

  • General Information
  • Current Individual Health Insurance Information
  • Information About You & Your Spouse
  • Benefits Desired
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Best Time To Call
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E-Mail Address *
Currently have health insurance? *

Carrier (Company) Name (not agency) *
Policy Expiration Date
/ /
Premium Amount
Years Insured
Please give a brief description of your current health plan, if applicable
Please enter information below for all to be covered.
Name
Self
Spouse
Date of Birth
Self
/ /
Spouse
/ /
Sex
Self

Spouse

Marital Status
Self

Spouse

Height
Self
Spouse
Weight
Self
Spouse
Smoker
Self

Spouse

Have you had any of the following health conditions
Self



Spouse



Major Medical Deductible *
Dental Coverage *

Disability Insurance *

Life Insurance *

Optional Pregnancy Coverage *

Supplemental Accident Coverage *

PPO Option *

HMO Option *

Any existing health problems that could affect premium? Please explain. *
Additional Comments or Questions
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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  Stalwart Insurance, LLC
2550 Boyce Plaza Rd #120
Pittsburgh, PA 15241 412-677-2312
Stalwart Insurance has assembled the finest, most experienced, and successful staff of benefits professionals whose practical knowledge is matched by their ethics and integrity. We further arm them with continuous education, training and cutting-edge technical resources. These highly specialized consultants have built a reputation for excellence, and a tenacious pursuit of dominant agency growth.
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