Millin Insurance Agency, Inc.

To contact us:

Phone: 215-343-8455 or

800-648-4060 (PA only)

Fax: 215-343-4001

Comments:

Quote Request Formxx

Please answer the following questions that will give us some basic information for your quote. Thank You!

1. Type of Business:

2. Source (referred by):

3. Type of Insurance needed:

4.  # of Years in Business:

5. Quote needed by:

6. Current Insurance Carrier:

7.  # Claims files in last 5 yrs:

8.  # of other brokers quoting:

E-Mail:

Phone:

Country:

Zip Code:

City:

State:

Address:

Name:

©2004-2005 Millin Insurance Agency, Last Updated December 2004