Request A Quote - Fairfield North Financial Network

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.

INSURED PEOPLE

Who will be insured?

Please enter some basic insurance information about the employees who will be insured under this policy, OR if a large amount of insured people use the "Upload Census File" process below (and check out our sample file for format and fields).

Census File

Please upload your Excel census file here (XLS or CSV format). You DO NOT have to Upload and fill out the fields below, just one or the other will do. For more than 5 employees, email your spreadsheet to info@fairfield-north.com or upload below.

Download our sample Census File to get started...

Upload Your Census File

Insured Info 1

First Name1 Last Name1 Zip Code1 Birth Date1

Gender1 M F Spouse1 Yes No

Insured Info 2

First Name2 Last Name2 Zip Code2 Birth Date2

Gender2 M F Spouse2 Yes No

Insured Info 3

First Name3 Last Name3 Zip Code3 Birth Date3

Gender3 M F Spouse3 Yes No

Insured Info 4

First Name4 Last Name4 Zip Code4 Birth Date4

Gender4 M F Spouse4 Yes No

Insured Info 5

First Name5 Last Name5 Zip Code5 Birth Date5

Gender5 M F Spouse5 Yes No

By clicking SUBMIT I authorize Fairfield North Financial Network, LLC 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 Fairfield North Financial Network will take all reasonable precautions to safeguard my data and if no further contact or authorization given to destroy all information I have submitted.

Agree to Terms*

Thank you for your submission. Fairfield North Financial Network will assess this data and get back to you immediately.

Jay Mora, Owner & Managing Partner
jay@fairfield-north.com

IMPORTANT NOTICE: Please know that no coverage will be bound or modified using online forms or e-mail without express confirmation from Fairfield North Financial Network, LLC.