• Home   • Products/Services   • Claims Information   • About Us   • Companies   • Resources   • Get-A-Quote Home Owner's Click Here Mike Kirgis Insurance Agency   616-527-1010   Now you can apply online direct with us! Please fill out the form below to receive the most accurate automobile insurance quote. If you are looking for a quote on homeowners insurance, please click here. AUTOMOBILE INSURANCE QUOTE FORM Customer Info:   Full Name: Phone Number: Email Address: (Required) Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: Vehicle Info:   Vehicle #1   Year: Make: Model: Vehicle ID#: Vehicle #2   Year: Make: Model: Vehicle ID# Vehicle #3   Year: Make: Model: Vehicle ID# Driver Info:   Driver#1   Name: Date of Birth: License#: Vehicle Driven: Select One Work School Pleasure How many miles one way? Do you have health insurance? Yes No Tickets or accidents in last 3 years? Yes No If yes, what kind and date of occurrence: Driver#2   Name: Date of Birth: License#: Vehicle Driven: Select One Work School Pleasure How many miles one way? Do you have health insurance? Yes No Tickets or accidents in last 3 years? Yes No If yes, what kind and date of occurrence: Additional Information: Member of any groups?:   Senior College Gradate Credit Union Professional (teacher, engineers, CPA, doctor) Other   Current Insurance Company? Current Bodily liability limits?   50/100 100/300 250/500 500/500 Other   Deductible Comprehension Deductible   Vehicle 1 Vehicle2 Vehicle3 100 100 100 250 250 250 500 500 500 Other Other Other Collision Deductible   500 1000 Other Board Form Basic   Home Owner Yes No