Roger Kesterke Insurance Agency | Insurance Agency | Auto Insurance | Homeowners Insurance | Life Insurance | Berrien County | Southwestern Michigan

Please fill out the following for a auto insurance quote

Names & Date of Birth for family members:

Driving Record (accidents & tickets) going back five years:

Year, Make, Model, and Vin # of all vehicles (Value if conversion van):

Discounts: Group, Good Student Discount, Multi-Policy, etc:

Who drives which vehicle and how are vehicles driven?

Current insurance company:

Expiration Date:

Best time & place to reach you:

Please fill out the following for a homeowners insurance quote

Birthdate of Household Members:

Desired Coverage Amount:

Liability and Medical Payment Amounts:

Construction of Home and Year Built:

Deductible Amount:

# of Families in Home:

Wood Stove?

Within 1000' of Fire Hydrant?

Miles to Fire Department:

Inside or Outside City Limits:

Fire Extinguisher/Smoke Detector/Dead Bolts?

Any Losses in the Past 5 Years?

Best time & place to reach you:

Other Coverage You're Interested In: (please describe)