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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.

Fill out this questionnaire completely for a free quote! (or e-mail us and ask us to contact you)
Vehicle information, vehicle #1:
Year Ex. 2006 Make
Model Serial #?
Usage?
Leased vehicle?
Does this vehicle have Air Bag(s)?
Does this vehicle have Automatic Seat Belts?
Does this vehicle have Anti-lock Brakes?
Does this vehicle have Day-time Running Lights?
Does this vehicle have an Anti-theft device?
What is your current Comprehensive deductible?
Do you carry full glass?
What is your Collision deductable?
Which Operator drives this vehicle most?
Vehicle information, vehicle #2:
Year Ex. 2006 Make
Model Serial #?
Usage?
Leased vehicle?
Does this vehicle have Air Bag(s)?
Does this vehicle have Automatic Seat Belts?
Does this vehicle have Anti-lock Brakes?
Does this vehicle have Day-time Running Lights?
Does this vehicle have an Anti-theft device?
What is your current Comprehensive deductible?
Do you carry full glass?
What is your Collision deductable?
Which Operator drives this vehicle most?
Vehicle information, vehicle #3:
Year Ex. 2006 Make
Model Serial #?
Usage?
Leased vehicle?
Does this vehicle have Air Bag(s)?
Does this vehicle have Automatic Seat Belts?
Does this vehicle have Anti-lock Brakes?
Does this vehicle have Day-time Running Lights?
Does this vehicle have an Anti-theft device?
What is your current Comprehensive deductible?
Do you carry full glass?
What is your Collision deductable?
Which Operator drives this vehicle most?
Vehicle information, vehicle #4:
Year Ex. 2006 Make
Model Serial #?
Usage?
Leased vehicle?
Does this vehicle have Air Bag(s)?
Does this vehicle have Automatic Seat Belts?
Does this vehicle have Anti-lock Brakes?
Does this vehicle have Day-time Running Lights?
Does this vehicle have an Anti-theft device?
What is your current Comprehensive deductible?
Do you carry full glass?
What is your Collision deductable?
Which Operator drives this vehicle most?

  Driver Information: Driver #1
  Full Name
  Sex
  Street Address
  City
  State
Zip
  E-mail Address
  Telephone   Ex. 716-665-4100
  Fax   Ex. 716-665-4100
 
  Residence Occupancy
  Date of Birth   
Age
  Marital Status
  Driver License / Permit Number  (9 digits)
  State Licensed
  Social Security Number
  Number of years Licensed
 
Driver training course completed?
Defensive Driving Course completed within last 3 years?
Have you ever had a DWI, DUI, DWAI, etc.?
If yes, when?   
  Driver Information: Driver #2
  Full Name
  Sex
 
  Date of birth   
  Age
  Relationship
  Driver License / Permit number (9 digits)
  State Licensed
  Social Security number
  Number of years licensed
 
Driver Training course completed?
Defensive Driving Course completed within last 3 years?
Have you ever had a DWI, DUI, DWAI, etc.?
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?
 
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?
What is your current premium?
What is your current "Bodily Injury Liability Limit?"
 
What is your current"Property Damage Liability Limit?"
 



Thank you for your information.

We will obtain your driving record, insurance score,
claim history, etc. for you!

All you have to do is submit this quote and we will contact you!
How would you like us to contact you? 

Additional Comments:
(C) 2010 Ames Insurance
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