Millenium Insurance Services, Inc.

Home

About Us

Online Forms

FAQ's

Contact Us

We welcome the opportunity to assist with your transportation insurance. In order to obtain proposals, we must submit all of the following information to the carriers we feel would give us the best quote for the coverage you desire. Failure to provide all of the information will prohibit us from being able to obtain a competitive quote. Please call if you have any questions.

If your company has more than 5 trucks, you cannot use this online quote form.
Please click here to print out the form and fax it to us at 210-930-5045.

If your company has 5 trucks or less, you can either fill out the form below or
click here to print out the form and fax it to us at 210-930-5045.

	Contact Information: Name: Address: Phone #: Fax #: MC or DOT Number: Return Email Address:
	Limit of Liability: Choose your Liability amount: Do you need Personal Injury Protection: Do you need Uninsured Motorist Protection: Do you haul containers for the shipping lines or railways:
	Cargo Limit: Please enter your Cargo limit: Do you need Reefer Breakdown:
	FEIN# or SSN#: Please enter your FEIN # or SSN #:

Equipment List: (Value if requesting Physical Damage)

	Year	Make	Model	VIN #	Value $
Equip 1
Equip 2
Equip 3
Equip 4
Equip 5

Trailers:

	Type	Year	Make	Model
Trailer 1
Trailer 2
Trailer 3
Trailer 4
Trailer 5

Driver's List: (Please fax an MVR for each driver to 210-930-5045.)

	Name	DOB	License #	Hire Date	Years Exp
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5

Loss Run Reports:

Please fax Loss Run Reports for a minimum of the past 3 years to 210-930-5045.

IFTA Reports:

Please fax the last 4 quarters of your IFTA Reports to 210-930-5045.

Cities Most Traveled:

Please enter the cities most traveled:

Commodities You Haul:

Please enter the commodities you haul
and the percentage of each: