John and Greg Milburn, Brokers
100 Rue Street Francois, Suite 207, Florissant, MO 63031
St. Charles: 636-928-2507 | Florissant: 314-837-1078| Fax: 314-837-5815
john@milburnagency.com & Greg@MilburnAgency.com

Established in

1963

Get a Quote

Auto Insurance Form:

We are happy to provide a free, no-obligation auto insurance quote. We represent many fine companies, and we will be happy to check all of their rates to provide you with the best estimate.

For auto insurance, we represent AAA Auto Club, AIG, Electric, Foremost, The Hartford, Safeco and Progressive.

If you prefer, we can fax, e-mail or phone you with the estimate. Just let us know what information you need. We are happy to serve.

Home Insurance Form:

We are happy to provide a free, no-obligation home insurance quote. We represent many fine companies, and we will be happy to check all of their rates to provide you with the best estimate.

For home insurance, we represent AAA Auto Club, Electric, Foremost, The Hartford and Safeco.

If you prefer, we can fax, e-mail or phone you with the estimate. Just let us know what information you need. We are happy to serve.

Life and Health Insurance Form:

We are happy to provide a free, no-obligation life or health insurance quote. We represent many fine companies, and we will be happy to check all of their rates to provide you with the best estimate.

For life insurance, we represent American National, Banner Life, ING, Lincoln Benefit, John Hancock, MetLife, Prudential, Transamerica, United of Omaha, and West Coast Life.

For health insurance, we represent UnitedHealthcare (underwritten by Golden Rule), which is one of the most respected health insurance carriers in Missouri.

If you prefer, we can fax, e-mail or phone you with the estimate. Just let us know what information you need. We are happy to serve.

Please complete the following Auto Insurance form and click Submit. We will contact you as soon as possible regarding your request.
Last Name
Address Line 2
City
State
Zip Code
Bold = Required Field
Contact Information
First Name
Address Line 1
Marital Status
Gender
Date Of Birth (2/15/75)
State Licensed
Home Owner
Current Policy Information
Current Insurance Carrier (Not Agency)
Expiration Date
Length of Time Continuously Insured
Second Driver Information
First Name
Gender
Date of Birth (2/15/75)
Marital Status
State Licensed
Vehicle 1 Information
Requested Coverage
Bodily Injury
Property Damage
Uninsured/Underinsured Motorist
Comprehensive Deductible
Collision Deductible
Full Glass?
Towing?
Rental?
Vehicle 2 Information
Vehicle 2 Year
Make
Model
Requested Coverage
Comprehensive Deductible
Collision Deductible
Full Glass?
Towing?
Rental?
Additional Information
Additional Comments
Please give additional comments about coverage you desire. For additional drivers, please enter their names, dates of birth, states licensed and relations to you. For additional vehicles, enter their years, makes, models and VIN numbers. Thank you.
Model
Make
Vehicle 1 Year
Can we check your credit?
Phone Number for Insured
Occupation
Education Level
Education Level
Occupation
Drivers License Number (optional)
Vehicle ID Number (VIN)
 (optional)
Vehicle ID Number (VIN)
 (optional)
Vehicle ID Number (VIN)
 (optional)
Rental?
Towing?
Full Glass?
Collision Deductible
Comprehensive Deductible
Requested Coverage
Model
Make
Vehicle 3 Year
Vehicle 3 Information
Vehicle 4 Information
Vehicle 4 Year
Make
Model
Requested Coverage
Comprehensive Deductible
Collision Deductible
Full Glass?
Towing?
Rental?
Vehicle ID Number (VIN)
 (optional)
Occupation
Education Level
State Licensed
Marital Status
Date of Birth (2/15/75)
Gender
First Name
Third Driver Information
Fourth Driver Information
Name
Gender
Date of Birth (2/15/75)
Marital Status
State Licensed
Education Level
Occupation
Last Name
Last Name
Last Name
Email Address
Good Student Discount
Good Student Discount
Good Student Discount
Fill out the form below and click "Submit." We will get back to you as soon as possible regarding your quote.
First Name
M.I.
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
E-Mail Address
Phone
Date Of Birth (2/15/75)
Bold = Required Field
Current Policy Information
Current Insurance Carrier (Not Agency)
Policy Expiration Date
Amount of Dwelling Insurance
Deductible
Home Information
How Long at Present Address?
Previous Address (If Less Than Two Years)
Numbers of Claims in the Last Three Years
Year Home Was Built
Square Footage of Home (Excluding Basement and Garage)
Structure Information
Type
Construction
Age of Roof
Foundation
Garage
Features
Bathrooms
# of Full
Bathrooms
# of Half
Basement
Square Feet
Porch (Square Feet)
Number of Fireplaces
Additional Features
Electrical System
Amps
Heating System
Woodstove
Trampoline
Pool
If Yes for Pool
Slide / Diving Board
Height of Fence
Pets
Losses?
Any Losses in the Last Five Years?
If yes, please explain:
Please give any additional comments about the coverage you desire:
Can we check your credit?
Do you have a mortgage?
Do you have a second mortgage?
We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.
First Name
M.I.
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Bold = Required Field
Person to Be Insured
Date of Birth
Gender
Marital Status
Height
Weight
Has this person used any tobacco products in the past 12 months?
Is this person an expectant mother?
Select any of the following that the person to be quoted has been diagnosed with (in the past 10 years):
If you've selected any of the above, please provide the date of onset, diagnosis, and current status:
Does this person take any medications?
If you answered Yes to medications, please list medication name and dosage:
Contact Information
First Name
Last Name
Address
City
State
Zip Code
Phone Number
E-Mail Address
UnitedHealthcareCar & house

Health Insurance for individuals and families!

Get a quote, compare health plans, and even apply on-line!
Just click the logo UnitedHealthOne below:

Please hit Submit Button (below)
 when done filling out Auto Insurance Form.
  Thank you!

Please hit Submit Button (below)
 when done filling out Home Insurance Form.  Thank you!

Please hit Submit Button (below)
 when done filling out Health and Life Insurance Form.
Thank you!

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