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Buffalo Insurance Agency LLC
(716) 675-2000

(716) 675-2531

Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

Last Name
City
State
Zip Code
E-mail Address
Bold = Required field
Contact Information
First Name
Address
Second Driver Information
Name
D.O.B.
Vehicle 1 Information
Vehicle 1 Year
Make & Model
Vehicle 2 Information
Vehicle 2 Year
Make & Model

Please give additional comments about coverage you desire. For additional drivers, please enter Name, Date of Birth, State Licensed and relation to you. For additional vehicles, enter Year, Make, Model and VIN #. Thank You.
Current Liability Limits
Comp & Collision?
Current Coverage
D.O.B.
Phone
Vehicle 3 Year
Make & Model
Vehicle 4 Year
Make & Model
No Carrier
Current Carrier
Uninsured Motorist
Bodily Injury
Requested Coverage
Uninsured Motorist
Bodily Injury
Requested Coverage
Uninsured Motorist
Bodily Injury
Requested Coverage
Uninsured Motorist
Bodily Injury
Requested Coverage

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Additional Comments
Vehicle 3 Information
Vehicle 4 Information
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