700 West Center Street, West Bridgewater, Massachusetts 02379
7 Jonathan Lane, Chelmsford, Massachusetts 01824
5693 St. George Ave., Westerville, Ohio 43082

700 West Center St.,
West Bridgewater,
MAs 02379
p:866.427.0087
f:508.427.6187

7 Jonathan Lane,
Chelmsford, MA 01824
p:866.427.0087
f:508.427.6187

5693 St. George Ave.,
Westerville, OH 43082
p:866.427.0087
f:508.427.6187

Request for Quotes

Employer Group Quote

Complete and submit the required form(s) and we will provide
you with quote from our nation's best rated insurers.

For groups of 2 or more, please print our Medical Census (for medical or dental plans) and/or Disability Census (for anything other than medical or dental). Please complete the form(s) and return by fax (508-427-6187) or mail to Orchard Financial Services, 700 W. Center Street, Suite 10, W. Bridgewater, MA 02379.

Census can be done in Excel and emailed.

The Medical Census and/or Disability Census is not necessary for one employee.
Please complete the form below.

Business Name:

Contact Person:

City/Town, State, Zip:

Phone:

Best time to Call: Please Select 8:00am-11:00am 11:00am-2:00pm 2:00pm-5:00pm 5:00pm-8:00pm

E-Mail:

E-Mail Confirmation: The e-mail doesn't match.The E-Mail doesn't match.

Benefit Provider: years

Years in Business:

Company Contribution:

Number of Carriers in the last 5 years:

Business Type:

SIC#:

Renewal Date:

Product: Please select Medical Dental Short/Long Term Disability 401(k) Pension Plans Vision Voluntary Employee Plans Group Life

Employee Name:

Gender: Please Select Male Female

Election Status (see legend above):

Date of Birth (mm/dd/yyyy):

Residence Zip Code:

For Security Purposes please identify the image to the right:
(lower case letters)

 

 

Actual premiums and coverage availability will vary depending upon age, sex, state, health history and tobacco use. THIS IS NOT AN OFFER OR CONTRACT TO BUY INSURANCE PRODUCTS, but rather a confidential informational inquiry. All information submitted is strictly confidential, and will be given to an insurance professional licensed in your state of residence, who will contact you and provide your quote directly. Further transmissions of this email may be stopped at no cost to you.

Online Forms: Person Insurance Quote and Employer Request for additional Infomation
PDF Forms: Medical and Dental Census and Life Insurance and Disability Census
For any other coverages not noted please contact us by phone or email.