Are your competitors spending less on their employee medical claims?

Home/Auto Discount Quote Form

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no obligation quote. Please be as detailed as possible to get the most accurate quote. All information is kept confidential and secure via our encrypted server.

Tell Us Your Insurance Needs

First Name *

Last Name *

Address *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

Best Time To Call

Open the time view popup.

Date of Birth *

E-Mail Address *

Type of Residence

Primary Residence?

Yes
No

Square Footage of Location

Construction Type

Year Building Built

Number of Stories

Heating Type

Age of Heating System

Type of Roof

Age of Roof

Pool

Dogs

Year plumbing was last updated

Year electrical was last updated

Claims/Property losses past 5 years

Estimated Value

Fire Sprinklers?

Yes
No

Do You Have an Alarm System?

Yes
No

Other Questions

Do you have any high value items? (jewelry, silver, furs, fine arts)

Yes
No

Coverage Information

Personal Contents Amount

Deductible

Family Liability Protections Amount

Additional Comments or Questions

Current Auto Insurance Information

Company Name (not agency)

Policy Expiration Date

Years Insured

Premium Amount

Own or Lease

Vehicle Identification Numbers

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

If VIN numbers have been given then no vehicle information is required

Vehicle 1

Year, Make, Model

Air Bag?

Vehicle 2

Year, Make, Model

Air Bag?

Vehicle 3

Year, Make, Model

Air Bag?

Vehicle 4

Year, Make, Model

Air Bag?

Vehicle 5

Year, Make, Model

Air Bag?

Vehicle 6

Year, Make, Model

Air Bag?

All Licensed Drivers in Household

Driver 1 Name

Date of Birth *

D.L.#

Driver 2 Name

Date of Birth

D.L.#

Driver 3 Name

Date of Birth

D.L.#

Driver 4 Name

Date of Birth

D.L.#

Driver 5 Name

Date of Birth

D.L.#

Driver 6 Name

Date of Birth

D.L.#

In the last 3 years have you had any Accidents/Claims?

In the last 5 years have you had any Minor or Major Violations?

Collision Deductible

Comprehensive Deductible

Liability

Uninsured / Underinsured Motorists

Personal Injury Protection (PIP)/Med Pay

Rental?

Towing?

Life Insurance

In school now?

Taking driver's ed?

In order to determine your eligibility, I am required to verify your loss history and credit history using consumer reports.

You understand and agree that any personal information about you that you provide will be used to run these reports.

You have the right to access and correct all personal information collected.

Do you understand and agree with the information contained in the privacy Statement?

Yes
No

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.

Insurance Websites Designed and Hosted by Insurance Website Builder

Our Customer Feedback

Our latest blogs

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.

We're here for you

Home Page/ About Us/ Contact Us/ Our Blog/ Latest News/ Join Our Newsletter/ Refer A Friend

Quick Help Links

Quote Forms/ Service Forms/ File a Claim/ Make a Payment/ Insurance Glossary/ FAQs/ Drug Costs Benefits Toolkit