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Agnew Insurance Agency, Inc.

269-488-5907716 W Milham Ave Portage, MI 49024Email us269-488-5907

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Agnew Insurance Agency

Independent Insurance Broker and Agent | Kalamazoo MI

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Home
Get A Quote
Contact

Get A Quote

Please select and complete one of our forms below so we can help you find the right coverage for you.

Auto Insurance

Home Insurance

Business Insurance

Auto Insurance

Please use this form to tell us more about the type of home insurance you’d like more information on.

Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Residence
Please tell us more about your primary residence.
Occupation
Phone*
Email*
Vehicle Information
Vehicle
Year*
Make*
Model*
Vehicle Identification Number (VIN)
Vehicle uses*
- Business
- Pleasure
- School
- Work
Owner
Name on Title
First Last
Purchase Date
Month
Day
Year
Ownership
- Lease
- Loan
- Own
Loan/Lease Company
Lease/Loan Company Address
Add Another Vehicle?
- Yes
- No
Vehicle Information #2
Vehicle #2
Year*
Make*
Model*
Vehicle Identification Number (VIN)
Vehicle uses*
- Business
- Pleasure
- School
- Work
Owner #2
Name on Title
First Last
Purchase Date
Month
Day
Year
Ownership
- Lease
- Loan
- Own
Loan/Lease Company
Lease/Loan Company Address
Driver Information #1
Name*
First Last
Driver License Number*
Date of Birth*
Month
Day
Year
Annual Mileage*
Estimated miles
Driver Additional Info
Select all that applies
- Young driver (under 18 years old)
- Completed driver training
- Qualifies for good student discount
Do you want to add another driver?
- Yes
- No
Driver Information #2
Name*
Driver #2 First Driver #2 Last
Driver License Number*
Date of Birth*
Month
Day
Year
Annual Mileage*
Estimated miles
Driver Additional Info
Select all that applies
- Young driver (under 18 years old)
- Completed driver training
- Qualifies for good student discount
Coverage Information
Coverage Type
- Best Coverage
- Lowest deductible
- Lowest rate
- State minimum
Coverage Options
Select all that applies
- GAP / replacement cost
- Medical payments
- Rental reimbursements
- Towing & roadside assistance
Current Auto Insurance Carrier
Comments
Comments
How did you hear about us?*
- Google Search
- Google Ad
- Prior Client
- Referral
- Word of Mouth
Referred By
Who can we thank for referring you to us?
Captcha

Home Insurance

Please use this form to tell us more about the type of auto insurance you’d like more information on.

Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Occupation
Current Home Insurance
Do you currently have a homeowner insurance policy?
- Yes
- No
Insurance Company
Coverage amount
Renewal date
MM slash DD slash YYYY
# of claims in last 5 years
Home Information
Year built
Type
Stories
Construction
Foundation
Age of electric
Age of plumbing
Age of heating
Basic Interior Features
Living space
# of full baths
# of half baths
# of chimneys
# of hearths
Addtional Interior Features
Please select all the apply.
- Finished basement
- Central air conditioning
- Security system
Basic Exterior Features
Garage type
Garage size
Roof type
Roof age
Additional Exterior Features
Please select all the apply.
- Deck
- Screened-in porch
- Outdoor pool
Additional Information
Please select all the apply.
- I’d like my jewelry to be covered
- I have pets
Optional Coverage
Coverage Options
Please select all the apply.
- Appliance breakdown
- Flood
- Identity Theft
Comments
Comments
How did you hear about us?*
- Google Search
- Google Ad
- Prior Client
- Referral
- Word of Mouth
Referred By
Who can we thank for referring you to us?
Captcha

Business Insurance

Please use this form to tell us more about your company and the type of business insurance you’d like more information on.

"*" indicates required fields

Business Information

Business Name*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Years in Business

Legal Entity

Annual revenue

# Of Owners/Partners

# Of Full-time Employees

# Of Part-time Employees

# Of Sub-contractors

Description of Operations

Annual Payroll

Contact Information

Name*

First Last

Phone*

Email*

Title

Business Insurance

Commercial/Business Insurance Products

Please select all that applies.

General Liability

Commercial Property

Commercial Auto

Commercial Umbrella

Workers Compensation

Bonds

Employee Benefits

Products

Please select all the applies.

Group health insurance

Group life insurance

Group disability insurance

401K / retirement plans

Supplemental plans / AFLAC

Key man life insurance

Key man disability insurance

Deferred compensation

Comments

How did you hear about us?*

Google Search

Google Ad

Prior Client

Referral

Word of Mouth

Other

Referred By

Who can we thank for referring you to us?

Captcha

716 W Milham Ave, Portage, MI 49024 | 269-488-5907

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Get A Quote

Please select and complete one of our forms below so we can help you find the right coverage for you.

Personal Information

Vehicle Information

Vehicle

Owner

Vehicle Information #2

Vehicle #2

Owner #2

Driver Information #1

Driver Information #2

Coverage Information

Comments

Personal Information

Current Home Insurance

Home Information

Basic Interior Features

Basic Exterior Features

Optional Coverage

Comments

Business Information

Contact Information

Business Insurance

Employee Benefits

Comments