Request A Quote

 Your Agent: Jeffrey J. Mora
Vice President, Employee Benefits
Email:
Phone: 203-894-3129

We follow the highest industry standards to safeguard the confidentiality of your personal information and secure the transmission of your information from your computer. Please fill out this form as completely as possible to ensure an accurate quote.

Quote will take approximately 3-5 minutes to complete.

Request A Quote
Contact Person’s First Name:
Contact Person’s Last Name:
Legal Company Name:
Street Address (No P.O. Boxes):
City:
State:
Zip:
Contact E-mail:
Business Telephone:
Alternate Telephone:
Are you replacing an existing insurance policy?
Number of employees to be offered health insurance:
Number of employees expected to enroll:
Select your most current insurance company:
When does your current policy expire?
(enter zeros if not currently insured)
 Month Day Year
How long have you been insured with current company?
 Years Months
How long have you been continuously insured? Years Months


 

Who will be insured?
Please enter some basic insurance information about the employees. Be as accurate as possible.

  First Name Last Name Home Zip Code Birth Date Gender Spouse? Children  



Or upload your excel census file here (optional):




By clicking SUBMIT I authorize Fairfield County Bank Insurance Services, LLC (FCBI) to use this information to contact those insurance companies licensed in the state of NY and/or CT to provide confidential health insurance quotes regarding my group. I further understand and expect that FCBI will take all reasonable precautions to safeguard my data and if no further contact or authorization given to destroy all information I have submitted.


 

IMPORTANT NOTICE: Please know that no coverage will be bound or modified using online forms or e-mail without express confirmation from FCBI.