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Home > Life > Individual Life Insurance Quote Request
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Individual Life 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
  • Information About You & Your Spouse
  • Medical Background
  • Life Coverages
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Best Time To Call
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E-Mail Address *
Please enter information below for all to be covered.
Name
Self
Spouse
Date of Birth
Self
/ /
Spouse
/ /
Sex
Self

Spouse

Marital Status
Self

Spouse

Annual Household Income *
Height
Self
Spouse
Weight
Self
Spouse
Have you had any of the following health conditions
Self



Spouse



Have you used any form of tobacco products? (cigarettes, pipe, chew, nicotine gum or patches) in the Past 12 months *

Have you ever been rated or declined for life insurance? *

If so, why?
Have you ever been treated for high blood pressure or cholesterol? *

Has any member of your family (parent or sibling) died from coronary artery disease prior to age 60? *

Is there a family history of colon or prostate cancer (for male applicant) or breast, ovarian, or colon cancer (female applicant) in a parent or sibling prior to age 60? *

Are you currently taking or have you been advised to take any prescription medications? *

If so, what type and why?
Have you had a DUI / reckless driving conviction in past 5 years or 3 moving violations in the past 3 years? *

Amount of Coverage Requested
Self
Spouse
Type of Coverage
Self


Spouse


Disability Income
Self

Spouse

Long Term Care
Self

Spouse

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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