Ames Insurance

Get a Quote For Auto Insurance

Ames Insurance is an independent agency, which means we write insurance for many different companies.  By completing the questionnaire below you will give us the necessary information to offer you an accurate quote.

Complete this questionnaire completely for a free quote!  This form may also be used for motorcycles, snowmobiles, ATVs, boats, etc.  We will contact you for any additional information.

Vehicle information, vehicle #1:
Year	Ex. 2006	Make
Model		Serial # (VIN)
Usage?	Pleasure Commute	Number of miles one way?
Number of miles driven annually?

Leased vehicle?	No Yes
Does this vehicle have Air Bag(s)?	None Driver only Driver & Passenger side
Does this vehicle have Anti-lock Brakes?	No Yes
Does this vehicle have Day-time Running Lights?	No Yes
Does this vehicle have an Anti-theft device?	No Yes
What is your current Comprehensive deductible?	$100 $250 $500 $1000 $50 None
What is your Collision deductible?	$100 $250 $500 $1000 None
Which Operator drives this vehicle most?

Vehicle information, vehicle #2:
Year	Ex. 2006	Make
Model		Serial # (VIN)
Usage?	Pleasure Commute	Number of miles one way?
Number of miles driven annually?

Leased vehicle?	No Yes
Does this vehicle have Air Bag(s)?	None Driver only Driver & Passenger side
Does this vehicle have Anti-lock Brakes?	No Yes
Does this vehicle have Day-time Running Lights?	No Yes
Does this vehicle have an Anti-theft device?	No Yes
What is your current Comprehensive deductible?	$100 $250 $500 $1000 $50 None
What is your Collision deductible?	$100 $250 $500 $1000 None
Which Operator drives this vehicle most?

Vehicle information, vehicle #3:
Year	Ex. 2006	Make
Model		Serial # (VIN)
Usage?	Pleasure Commute	Number of miles one way?
Number of miles driven annually?

Leased vehicle?	No Yes
Does this vehicle have Air Bag(s)?	None Driver only Driver & Passenger side
Does this vehicle have Anti-lock Brakes?	No Yes
Does this vehicle have Day-time Running Lights?	No Yes
Does this vehicle have an Anti-theft device?	No Yes
What is your current Comprehensive deductible?	$100 $250 $500 $1000 $50 None
What is your Collision deductible?	$100 $250 $500 $1000 None
Which Operator drives this vehicle most?

Vehicle information, vehicle #4:
Year	Ex. 2006	Make
Model		Serial # (VIN)
Usage?	Pleasure Commute	Number of miles one way?
Number of miles driven annually?

Leased vehicle?	No Yes
Does this vehicle have Air Bag(s)?	None Driver only Driver & Passenger side
Does this vehicle have Anti-lock Brakes?	No Yes
Does this vehicle have Day-time Running Lights?	No Yes
Does this vehicle have an Anti-theft device?	No Yes
What is your current Comprehensive deductible?	$100 $250 $500 $1000 $50 None
What is your Collision deductible?	$100 $250 $500 $1000 None
Which Operator drives this vehicle most?

	Driver Information: Driver #1
	Full Name
	Sex	Male Female
	Street Address
	City
	State
	Zip
	E-mail Address
	Telephone	Ex. 716-665-4100
	Fax	Ex. 716-665-4100
	Residence Occupancy	Own Rent Live with relatives
	Date of Birth
	Age
	Marital Status	Married Single Divorced Separated
	Driver License / Permit Number	(9 digits)
	State Licensed
	Social Security Number
	Number of years Licensed
Driver training course completed? (if driver under age 25)		No Yes
Defensive Driving Course completed within last 3 years?		No Yes
Have you ever had a DWI, DUI, DWAI, etc.?		No Yes
If yes, when?

	Driver Information: Driver #2
	Full Name
	Sex	Male Female
	Date of birth
	Age
	Relationship	Spouse Child Other
	Driver License / Permit number	(9 digits)
	State Licensed
	Social Security number
	Number of years licensed
Driver Training course completed? (if driver under age 25)		No Yes
Defensive Driving Course completed within last 3 years?		No Yes
Have you ever had a DWI, DUI, DWAI, etc.?		No Yes
If yes, when?

	Other Licensed drivers in the household:
	Full Name
	DOB
	Drivers License #	(9 digits)
	Social Security #
	# Years Licensed

Current Insurance
Do you currently have an Auto insurance policy?
	No Yes, I have my own policy No, but I am formally listed on my parents policy
If "No" please skip to "How would you like us to contact you?"
What is the name of your current insurance company?
When does your policy expire?
6 or 12 month policy?		6 months 12 months
What is your current premium?
What is your current "Bodily Injury Liability Limit?"
	I have faxed a copy of my policy to you 716-665-3998 $25,000 per person, $50,000 per accident (25/50) 50/100 100/300 250/500 60,000 Combined Single Limit (60 CSL) 100 CSL 300 CSL 500 CSL Not sure
What is your current"Property Damage Liability Limit?"
	$10,000 $15,000 $25,000 $50,000 $100,000 not applicable because I have a combined single limit (CSL) Not sure

Thank you for your information. How would you like us to contact you?  E-mail Phone Fax Additional Comments: (e.g. additional driver info, additional vehicle info) Please enter this verification code in the box below: