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
Email
Email confirm
Benefits provider		years
Years in business
Company contribution
Number of Carriers 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 shown				use 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.